I hereby authorize the release of any medical information necessary to process this insurance claim. I understand that an insurance company may not pay for services that they consider to non-efficacious, not medically or therapeutically necessary, or ineligible (not covered by your policy, or the policy has expired or is not in effect for you or other people receiving services). In the event that my benefit was misquoted by my insurance company, I understand it is still my respponsibility to pay Dr. Sarah Allen & Associates. I am financially responsible for the payment at the time of service and that the session information is being submitted to my insurance company as a courtesy. My insurance company will reimburse me directly and any disagreement of reimbursement of benefits is between my insurance company and myself.