I hereby assign all medical benefits to include major medical benefits to which i am entitled, including but not limited to Medicare, Medicaid, Private Insurance and any other health plan to Dr. Felix Agbo and Sinai Internal Mediciine Specialists, PA.

This order will remain in effect until revoked by me in writing. A photocopy of the assignment is to be considered as valid and the original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize and said assignment to release all information necessary to secure paymeny.

I the guarantor named above, agree to be personally and fully responsible for the payment of any and all medical services, not covered by federal, state or commercial insurance or benefit program, that are provided by SINAI INTERNAL MEDICINE SPECIALISTS, PA to the above named individuals (including myself).

I understand that I am personally and fully responsible for the payment of all applicable co-payments and deductible. I understand that all applicable paymentsare due at the time of service.

Name of Guarantor *

Name of Witness*