Advanced Heart Care Inc.

I hereby assign all medical and/or surgical benefits, including Medicare, private insurance, and/or any other plan to Advanced Heart Care, Inc. This assignment will remain in effect for one year from date signed.  A scan and/or photocopy of this assignment will be considered as valid as an original. I understand that I am financially respoinsible fro all charges whether or not paid by insurance.  I hereby authorize said assignee to release information necessary to secure payment.  I hereby authorize Advanced Heart Care, Inc. to perform any  medical treatment necessary.

As a courtesy to other patients, we require 24 hours advance notice prior to any cancellation or rescheduling.