service unless prior arrangements have been made with our financial staff. We will send a courtesy bill to your insurance carrier on your behalf. Private Insurance Authorization for Assignment of Benefits/Information Release: I, the undersigned, authorize payment of medical benefits to MSDFP for any services furnished. I understand that I am financially responsible for

service unless prior arrangements have been made with our financial staff. We will send a courtesy bill to your insurance carrier on your behalf. Private Insurance Authorization for Assignment of Benefits/Information Release: I, the undersigned, authorize payment of medical benefits to MSDFP for any services furnished. I understand that I am financially responsible for