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 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.