I hereby authorize payment directly to Neurology LLP for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents. I authorize the release of any medical information needed to determine these benefits. I authorize the use of this signature on all insurance submissions. This authorization shall remain valid until written notice is given by me revoking said authorization.