I/We do hereby consent to and authorize the performance of all medical services and treatments deemed advisable by the physicians and staff of Mid Atlantic Retina (MAR) to me or to the above-named minor of whom I am the parent or legal guardian. I hereby certify that, to the best of my knowledge, all statements contained herein are true. I understand that, although the providers of MAR may or may not participate with my insurance carrier(s), I am financially responsible for any co-payments, deductibles, and payment for non-covered services or out of network services incurred for myself and/or my dependent(s). I furthermore agree to pay accrued interest, if applicable, collection expenses, and reasonable attorneys’ fees incurred to collect any amount I may owe. I also hereby authorize MAR to release information as necessary for and/or requested by the insurance company and/or its representatives for claims processing and payment. I fully understand this agreement and consent will continue until cancelled by me in writing.