LIFE MEDICAL , PA

4201 ,EXCELSIOR BL VD

ST.LOUIS PARK MN 55416

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    Assignment & Release: I,the undersigned,have insurance coverage,and assign directly to life Medical ,PA,All medical benefits,,If any otherwise payable to me for service rendered .I understand that I am financially responsibly for all charged whether of not payed by insurance.I here by authorize the doctor to release all information necessary to secure the payments of benefits.I authorize the use of this signature on all my insurance submissions. Unpaid patient balance over 90days old will be assessed a 1.5% monthly finance charge. Also liable for all legal and collection fees.