The parties appearing below hereby agree to the following conditions, covenants and terms regarding the assignment of health benefits appearing in the policy that has been presented to this office. I hereafter referred to as “Patient”, understand and voluntarily agree to assign all applicable health provisions pertaining to payments or benefits appearing in my insurance policy in consideration for treatment rendered by Dr. Douglas B. Gauthier or Dr. Anne-Laure Gauthier, referred to as “Doctor”. The patient, the policy holder, requests, orders and directs the insurance company to pay Dr. Douglas B. Gauthier or Dr. Anne-Laure Gauthier directly to his/her office at 6008 NW 9Hwy, Suite A, Parkville, MO 64152 or if my current policy prohibits direct payment to the doctor, I hereby understand that it is my responsibility to direct all payments to the address as follows: 6008 NW 9Hwy, Suite A, Parkville, MO 64152 for the sum due to the Doctor for treatment rendered. The patient gives the doctor exclusive right to secure the funds assigned the patient, including the right of securing counsel to represent the Doctor in the collecting all sums due for treatment rendered. The Doctor and Patient hereby enter into the assignment of benefits freely and voluntarily and evidenced by the signatures appearing below: that Patient and Doctor warrant that they have read this assignment of benefits and that each understand the legal effect of the same, and agree that each shall be bound by the covenant, terms and conditions appearing herein. A photocopy of this Assignment shall be considered as effective and valid as the original.