I request that payment under the above-named insurance program be made payable to Dallas Endoscopy Center, LTD 5327 N Central Expw #200, Dallas, Tx, 75202,
on any bills for services rendered to me. I understand that any portion unpaid by my insurance company is payable by me. I understan that if any of the insurance
information I have provided is incorrect or I fail to notify the center of any insurance changes that I am responsible for all facility fees.
I also authorize the center to release to my insurance company any information acquired in the course of my procedure. I agree that photographic copies of
this signed authorization shall be as valid as the original. I have received the Notice of Privacy Practices Information.
Dallas Endoscopy Center is privately owned by a group of physicians. Your physician may be an investor in this center. As a patient, you have the right to choose the
facility of your choice for health-related service.