My signature below acknowledges the following:
I hereby assign all medical and/or surgical benefits, to include major benefits to which I am entitled, private
insurance and any other health plan to Main Street Medical Services, PLLC.
This assignment will remain in effect until revoked by me in writing. A photocopy of this agreement is to be
considered valid as original. I understand that I am financially responsible for all charged whether or not paid by
said insurance. I hereby authorize said assignee to release all information to secure payment.