ARE YOU COVERED BY MEDI-CAL? ( ) YES ( ) NO -- IF YES, PLEASE SEE RECEPTIONIST.
HAS THIS OFFICE TREATED A MEMBER OF YOUR FAMILY? _________________________________
PLEASE SIGN AND RETURN TO RECEPTIONIST
I, the undersigned, assign directly to Dr. Kevin Ho, all surgical and medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance. I hereby authorize the doctor to realease all information necessary to secure the payment of benefits.