| understand that NYU School of Medicine, my treating physicians and their respective designees, will se and disclose my health information for all purposes necessary for treatment, payment and health care operations, including but not limited to area, Of information requesied by my insurance company (oF cartier) and any information necessary for discharge planning purposes. ASSIGNMENT OF INSURANCE: | hereby authorize my insurance benefits to be paid directly to NYU School of Medicine. | understand | am financially responsible for non-covered services. | authorize the release of any medical or other information | necessary to process insurance claims on my behalf FINANCIAL LIABILITY: have been provided a copy of the NYU School of Medicine financial policies and agree to the Specified terms. | Rereby agree to pay all charges due (or to become due) to NYU School of Medicine for care and treatment, including co-payments and deductibles as provided under my plan Benefits, if any, paid by a third party, will be Credited on account, understand that | will be responsible for any charges if any of the fosowing apply . My health plan requires prior referral by a Primary Care Physician (PCP) before receiving services at NYU Schoo! Of Medicine and | have not obtained such a referral or | receive services in excess of the referral, and/or . My heaith plan determines that the services | receive at NYU Schoo! of Medicine are not medically necessary and/or not covered by my Insurance plan, and/or . My health plan coverage has lapsed or expired at the time | receive services at NYU School of Medicine. andior . | have chosen not to use my health plan coverage, and/or . The physician | see does not participate with my health care plan, MEDICARE SIGNATURE ON FILE (Medicare Patients Only): | request that payment of authorized Medicare benefits be Prace eater fo me or on my behalf to all providers who treat me during my hospital stay or any services furnished to me by those providers. | authorize the holder of medical and other information about me to release to Medicare and its agents any information needed to determine related services. Patient's Medicare nt Mi i ANCILLARY SERVICES: | understand | may receive certain ancillary medical services while | am at NYU School of Medicine; such as, anesthesia, interpretation Of cardiac tests, imaging services (2.9. x-rays, MRis) and pathology specimen examination. | understand that some physicians may not provide services in my presence, but are actively involved in the course of diagnosis and treatment. "hereby authonze payment directly for these services under the policy(s) or plan(s) issued to me by my insurance carrer. understand that | may incur additional charges as @ result of these ancillary services: | agree to pay 3 charges due with respect to such services to the extent the charge is due after credits given for benetes paid on my behalf by any third party payor. CANCELED OR NO-SHOW APPOINTMENTS: | understand that, based on the policy of individual physician offices, | may newt @ cancelation fee if | do not provide the required notice of cancelation, or if | do not keep my appointment and have net canceled. ‘have been provided the Faculty Group Practice Patient Financial Policies. | understand the information listed above which has been fully explained to me. FIL “Gasrantor Signals Form Revised: 9/14/2016 EFTA00313913