Patient Name:_____________________________________         Date:__________________

CONSENT FOR SERVICES:

I request, authorize, and give consent for Dr. Jeffrey D. Reuben, PA (hereafter referred to as the “Provider”) to provide me with services and/or products. I understand that any services and/or products to be provided by Provider will be requested by my physician and will be provided under his direct supervision.

CONSENT FOR RELEASE OF MEDICAL INFORMATION:

I hereby authorize and given my consent to my physicians, and/or any holder of medical or other information about myself, to release any and all said information to Provider and its agents, employees and representatives.

CONSENT FOR RELEASE OF MEDICAL RECORDS TO INSURANCE CARRIER:

I hereby authorize and give my consent for Dr. Jeffrey D. Reuben, PA to furnish to my insurance carrier(s) or its agent(s), any information regarding my illness and/or therapy and agree to hold them harmless from any and all liability from same.

CONSENT FOR RELEASE AND USE OF MEDICAL INFORMATION:

I hereby authorize and five my unconditional consent to Provider, its employees and agents to release any medical and other information about myself to any local, state or federal health care regulatory bodies, private health care accrediting organizations with which Provider, is affiliated or seeks affiliation or to representatives of Provider’s Continuous Quality Improvement Committee.

IRREVOCABLE ASSIGNMENTS AND FINANCIAL RESPONSIBILITY:

In consideration of services rendered and to be rendered, I hereby irrevocably assign and transfer to Dr. Jeffrey D. Reuben, PA (hereinafter referred to as the "Provider"), all right, title and interest in all benefits payable for the health care rendered, which are provided in any and all insurance policies, employee benefit plans, and/or third party actions against any other person or entity from whom my dependents or I are entitled to recover (hereinafter referred to as "Benefits"). I further hereby irrevocably assign and transfer to the Provider all right, title and interest in any and all causes of action against all Insurance companies, employee benefit plans, third party administrators and/or other persons or entities responsible for payment of the Benefits (hereinafter referred to as "Responsible Parties"), I hereby appoint the Provider as my attorney in fact, with power of substitution, to sue or otherwise obtain payment of Benefits from the Responsible Parties. Said Irrevocable assignment and transfer shall be for the purpose of granting the Provider and Independent right of recovery against such Responsible Parties, but shall not be construed to be an obligation of the Provider to pursue any such right of recovery. I further authorize all Responsible Parties, to pay directly to Dr. Jeffrey D. Reuben, PA all Benefits and amounts due for services rendered by the Provider. I understand that if the Provider Iis not paid In full by proceeds of any Benefits, then this assignment does not release my obligation and liability to the Provider for payment of all services and items provided to me or the above referenced patient, by the Provider. In the event no Benefits are paid by the Responsible Parties, then I agree to pay Dr. Jeffrey D. Reuben, PA for all charges in excess of the Benefits paid. All payments will be made to Dr. Jeffrey D. Reuben, PA at 5555 West Loop South, Suite 360, Bellaire, Texas, 77401. The terms and consequences of these Irrevocable assignments and financial responsibilities have been fully explained to me to my understanding, or other individual(s) authorized to endorse this document in my behalf, and I have signed this document freely and without inducement other than the rendition of services by the Provider.

OTHER:

If the patient is unable to execute document, explain reason and attach power of attorney letter of guardianship or other written document evidencing power of attorney letter of guardianship or other written document evidencing power to bind patient; A duplicate copy of this document shall be accepted as original.

Signature of patient or representative_________________________________Date______________Witness_________________________________