I hereby assign all medical benefits to include major medical benefits to which i am entitled, including but not limited to Medicare, Medicaid, Private Insurance and any other health plan to Dr. Felix Agbo and Sinai Internal Mediciine Specialists, PA.
This order will remain in effect until revoked by me in writing. A photocopy of the assignment is to be considered as valid and the original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize and said assignment to release all information necessary to secure paymeny.