I hereby authorize my insurance benefits to be paid directly to LOHMAN ENDOSCOPY CENTER, LLC and understand that I am financially responsible for non· covered services and I will be billed separately for the facility and physicians fees. I also authorize the physician to release information required to process this claim. I understand and agree to cover a copay at the time of service. I authorize LOHMAN ENDOSCOPY CENTER, LLC to release any medical information in connection with these services to my referring and or primary physician. Consent to treatment: I understand that medical treatment is of urgent nature or necessary for the patient and such medical care, treatment, and procedures will be no guarantee as to the results which may be obtained. Patient Signature:
Current Medications, if any. Please list name, dose, frequency, and time taken.