I give my consent for medical treatment by the physicians or health care
provider of ABC-Obgyn. I authorize the release of any medical or other
information necessary to process this medical claim. I release all
insurance and third party payments to ABC-Obgyn. I understand
that I am responsible for co-payments and deductible payments. However, I
will be financially responsible for the services rendered that my
insurance company dictates are non-covered benefits.