I authorize the release of any medical treatment necessary to process a claim on any insurance policy. I hereby assign to and authorize payments to Joby L. Hurst, D.M.D., M.S., P.C., of all benefits payable under such insurance policy. “This information is given for the purpose of establishing an account and medical file with Joby L. Hurst, D.M.D., M.S., P.C. It is understood that I will be responsible for all present and future services. I DO UNDERSTAND THAT REGARDLESS OF THE INSURANCE COVERAGE THAT I HAVE, I AM RESPONSIBLE FOR PAYING ALL CHARGES. In the event of non-payment of charges for dental services rendered, I agree to pay all costs of collection, including a reasonable attorney’s fee, and I further waive all rights of exemption as to personal property under the constitution and laws of the State of Alabama. I have read this agreement and do understand its provisions.” *PLEASE BE AWARE THAT WHOEVER ACCOMPANIES THE PATIENT AND SIGNS ALL NECESSARY FORMS IS RESPONSIBLE FOR PAYMENT OF ALL PROCEDURES, REGARDLESS OF WHOSE INSURANCE THAT PATIENT IS COVERED UNDER. I understand and authorize all dishonored checks plus a processing fee if applicable to be electronically debited from my account.