I hereby assign, transfer, and set over to Abigail Neiman M.D., P.A., all of my rights, title and interest to my medical reimbursement benefits under my insurance policy.  I authorize the release of any medical information needed to determine these benefits.  This authorization shall remain valid until written notice is given by me revoking this authorization.  I understand that I am financially responsible for all charges whether or not they are covered by insurance.  Furthermore, I understand and have been informed that I will be responsible to pay a $25.00 fee if I do not call to cancel any scheduled appointments within 24hrs from the appointment. I also understand that I cannot receive adequate medical treatment if I neglect to keep scheduled appointments.