Release of Authorization
I authorize the release of any medical information necessary to my insurance claim(s). I agree that this authorization will cover all medical services rendered until such authorization is revoked by me. I agree that a photocopy of this form may be used in place of an original.
By checking this box I agree that my typed name will constitute my signature.
Assignment of Benefits
I authorize and request payment of medical benefits directly to my provider.
Check here if you would rather not receive periodic newsletters from IFC. We respect your privacy and will never give your email address to anyone.