I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicare, private insurance, and any other health plan to Ankle & Foot Care.

This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information to secure the payment.

Signed (parent if minor): __________________________________________________ Date: ________________________

Witness: ______________________________________________________________ Date: _________________________

"I request that payment of authorized Medicare benefits be made on the behalf to Ankle & Foot Care for any services furnished me by the physician or supplier. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits for related services."

Signed: _______________________________________________________________ Date: _________________________