I am authorizing VIP Fibroid Center to release all medical information (including, but not limited to,
information on psychiatric conditions, alcohol and drug abuse) requested by my health insurance carrier,
Medicare or any other third-party payers. I authorize VIP Fibroid Center to release all medical
information on to my referring physician and my primary physician. I authorize VIP Fibroid Center to
contact my insurance company or health plan administrator and obtain all pertinent financial information
concerning coverage and payments under my policy. I direct the insurance company or health plan
administrator to release such information to VIP Fibroid Center.
Assignment of Benefits: I request that payment of authorized insurance benefits be made on my behalf to
VIP Fibroid Center. I agree that these provisions will remain in effect until I provide written
revocation to VIP Fibroid Center.