I hereby authorize Patient Benefit Foundation and associates to examine and treat me. I also authorize the release to my insurance company any information acquired in the course of my examination or treatment. I hereby authorize payment directly to Patient Benefit Foundation for surgical and/or medical benefits otherwise payable to me for services rendered. If benefits payable to me I authorize my insurance company, Medicare or Medicaid to furnish to my doctor any information in the adjudication of any claim in regards to services furnished to me. I hereby authorize the use of a photographic reproduction of this authorization in place of the original. I also understand that in case of electronic transmittal of claims to insurance company the notation "Signature on record' will be used. This authorization is valid until I or my legally designated representative revokes it in writing. I verify that the above information is complete and accurate to the best of my knowledge.