Assignment of Insurance Benefits:
I hereby authorize direct payment of medical benefits to Good Health Physicians, LLC for
services rendered. I understand that I am financially responsible for any balances not covered by
Authorization to Release Information:
I hereby authorize Good Health Physicians, LLC to release to, and receive from, exchange
written or oral communication on any medical or other incidental information that may be
necessary for either medical care, claims processing or continuity of care between behavioral or
physical health providers.
Medicare Medicaid Medigap:
I certify that the information given by meis true and correct. I authorize the release of all records
to collect benefits on my behalf.