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I hereby authorize my insurance carrier, attorney or any third-party payer to pay directly to Tampa Bay Weight Loss Clinic, LLC dba Genesis Medical Clinic all charges submitted for services incurred by me. I understand I will be responsible for any and all charges not paid by my insurance company. I authorize Tampa Bay Weight Loss Clinic, LLC dba Genesis Medical Clinic to release information concerning my medical condition to my insurance company, employer, hospital, physician r attorney for the purpose of processing a claim. I assign payment directly to the physicians at Tampa Bay Weight Loss Clinic, LLC dba Genesis Medical Clinic which may be due from the Medicare program or any other insurance company, including supplemental insurance, which may cover in whole or part medical services which I have received. The authorization and assignment shall be valid until I notify Tampa Bay Weight Loss Clinic, LLC dba Genesis Medical Clinic in writing of the cancellation. A photocopy of this authorization shall be valid as the original copy.