Financial Agreement: • I acknowledge that, as a courtesy, GATEWAY HEALTHCARE may bill my insurance company for services provided to me. • I agree to pay for services that are not covered or covered charges not paid in full including, but not limited to, co – payments, co – insurance, deductibles and/or charges not covered by insurance. • I understand there is a $25 fee for returned checks. Third Party Collection : I understand GATEWAY HEALTHCARE may use the services of a third – party business associate or affiliated entity as an extended business office (“EBO Servicer”) for medical account billing and servicing. Assignment of Benefits: I hereby assign to GATEWAY HEALTHCARE any insurance or other third – party benefits available for health care services provided to me. I understand GATEWAY HEALTHCARE has the right to refuse or accept assignment of such benefits. If these benefits are not assigned to GATEWAY HEALTHC ARE, I agree to forward all health insurance or third – party payments that I receive for services rendered to me immediately upon receipt. Medicare Patient Certification and Assignment of Benefit: I certify that any information I provide, if any, in apply ing for payment under Title XVIII (“Medicare”) or Title XIX (“Medicaid”) of the Social Security Act is correct. I request payment of authorized benefits to be made on my behalf to GATEWAY HEALTHCARE by the Medicare or Medicaid program. Consent to Telepho ne Calls for Financial Communication: I agree that, in order for GATEWAY HEALTHCARE, EBO and/or collection agencies to service my account or to collect any amounts I may owe, I expressly agree and consent that GATEWAY HEALTHCARE and/or EBO and/or collecti on agents may contact me by telephone at any telephone number, without limitatio n of wireless, I have provided , o r GATEWAY HEALTHCARE , EBO and/or collection agents have obtained, or, at any phone number forwarded or transferred from that number, regarding the services rendered, or my related financial obligations. Methods of contact may include using pre – recorded/artificial voice messages and/or use of an automatic dialing device as applicable. A photocopy of this consent shall be considered as valid as t he original.