I hereby authorize Greater Michigan Orthopedics to release any information regarding my diagnosis and treatment to above stated insurance co, workman's comp carrier and/or physician. I request and authorize payment of medical benefits to Greater Michigan Orthopedics or the providing physician. I also release my medical records to the above named insurance companies, referring physician and myself upon request. If payment is not received within a reasonable length of time, the bill will then become my responsibility. I agree that if I carry an insurance that requires a referral (HMO), I will be responsible to obtain a referral from my primary care physician. I agree if I do not carry health insurance, I am responsible for all services rendered by the treating physician.