If I am entitled to benefits under Medicare, Medicaid, or any insurance policy or other health benefit plan
(covering me or anyone legally responsible for me), in consideration of services provided to me, I assign, transfer
and convey the benefits payable under such program, policy or plan for services rendered to me. I authorize payment
of these benefits directly, with such benefits being applied to my bill. I understand and acknowledge that this
assignment does not relieve me of financial responsibility for charges incurred by me or anyone on my behalf, and I
hereby acknowledge responsibility for and agree to pay charges not paid under this assignment, including any
coinsurance amounts, deductibles, Durable Medical Equipment, and any charges for service deemed to be non-covered,
not pre-certified, or not pre-authorized by my insurance plan.