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1. Acceptance of Service:
I understand by signing this agreement I authorize provisions of service to me in accordance with my attending physician by Sudhakaran Jegadeesh Inc.

2. Medical Information Authorization:
I hereby authorize release to Sudhakaran Jegadeesh Inc. All of my medical records pertaining to my medical history, services rendered to treatments received from my physician or hospital in order to process Insurance claims. I also hereby authorize release of my records to my Insurance carrier.

3. Assignments of Benefits:
I authorize direct payment of insurance benefits by my insurance company to Sudhakaran Jegadeesh Inc. In the event that my insurance carrier does not accept “Assignments of Benefits,” I understand that payments may be sent directly to me and that I am obligated to endorse and directly send such payment to you for my bills. Any amount received from the insurance carrier that I fail to remit will become my liability.

4. I also request payment of government benefits either to myself or to the party who accepts assignments above.

5. Financial Responsibility:
I understand that I am responsible for all charges not covered by my insurance (excluding Workman’s Compensation). I recognize that I am responsible for all Co-payments and deductibles or in the event that I have no insurance coverage or that my employer refuses to pay. I will be responsible for said payment and will make proper reimbursement thirty (30) days of notification for all charges.

6. I understand that Medicare will pay 80% of these charges after the deductible and Co-Insurance (if applicable) will pay 20% and deductible, but if not, the balance is my responsibility.

7. I the under signed, agree to pay Sudhakaran Jegadeesh Inc. On a timely basis for all evaluations, tests, and treatments rendered on behalf of myself or my designee and for any and all including reasonable attorney fees and cost and legal cost if necessary.

Accordingly, I Direct
A. That Sudhakaran Jegadeesh, Inc. shall have first priority retaining and charging lien (or simply lien) are hereby granted, on undersigned’s file and on any judgement or settlement against any part for which suit is now pending or may be brought at a later date and said liens shall remain operative until discharged
upon incurred by the undersigned.

B. Sudhakaran Jegadeesh Inc. Shall be paid directly and authorization for the same is hereby made, for undersigned’s insurer, or by any third party liable to undersigned for medical expenses, to pay Sudhakaran Jegadeesh Inc. As billed for purpose of payment or otherwise, I authorize Sudhakaran Jegadeesh Inc. at its discretion to release any and all of my medical records to any insurer or other party. I understand that I am the person primarily responsible for the charges and if my account is not fully paid by the insurer or other parties when due, I agree to pay the balance and late charges in the amount of 1 ½% per month computed and compounded monthly on any unpaid balance.

C. A copy of this assignment has the same effect as the original. I acknowledge that I have read or it has been read to me and I understand the above information.