I certify that I have read and agree to Callahan Clinic payment policy. I am eligible for the insurance indicated on this form and I understand that payment is my responsibility regardless of insurance coverage. I hereby assign to Callahan Clinic all money to which I am entitled for medical expenses related to the services performed from time to time by CC, but not to exceed my indebtedness to CC. I authorize CC to release any medical information to my insurance carrier or third party payer to facilitate processing my insurance claims. I understand that failure to pay outstanding balances within 90 days of notification of the amount due will result in submission to an outside collection agency and be charged a 40% fee. A $20.00 returned check fee will be charged for checks returned due to insufficient funds. I choose to receive communications from CC by text or e-mail at the number or address stated above, including but not limited to communications abotu appointments, feedback, treatment, and payment. I understand that such e-mails and texts may not be secure and there is a risk that they may be read by a third party. Comments submitted on surveys may be anonymously shared on the CC public website. Medicare Beneficiaries: I request that payment of authorized Medicare benefits to be made to CC. I authorize any holder of medical information about me to release to CMS and its agents any information needed to determine these benefits or the benefits payable for related services