Patient/Guarantor Please Read and Sign:
I request payment of health benefits to my attending physician whether it be Darrell C Belcher, M.D., Phillip Branson, M.D., Robert Kropac, M.D., or Frederick Morgan, D.O. for services rendered to me. I do however understand that I am responsible for all charges inccured. I authorize the Orthopedic Center of the Virginias to realease any information, verbal or written, to all parties involved regarding my medical condition. This is to include any medical records, reports, x-rays, or other related information. In the event that one of the above mentioned doctors should be overpaid, I hereby authorize Darrell C Belcher, M.D., Phillip Branson, M.D., Robert Kropac, M.D., or Frederick Morgan, D.O. overpayment to be applied to outstanding accounts with other physicians within this office.