Star Cardiology Care, PC

I, the undersigned, hereby certify and attest that I have sought evaluation, or medical advice from the staff at the office named above. I therefore authorize the medical staff and personnel to release my medical information to the insurance company listed above for the purpose of determining and receiving benefits for medical bills.

I understand and acknowledge the the medical staff will submit my claim to the insurance company on my behalf. I further understand that I will be held responsible for any amount of my medical bills not covered by my insurance policy or claims, and that I will be responsible for paying all deductible, fees, co-payments, and co insurance payments required.

I understand that any portion of my medical bills not covered by insurance will be billed to me at the address I have provided above. Non-compliance or defaulting on pa