By clicking the "I AGREE" checkbox, you also indicate that you accept financial responsibility, if any, for the Ideal Option services you receive. We may verify your insurance benefits and may submit a claim to your health insurer for payment. Without waiving your financial responsibility, you agree to assign your right to medical benefits to Ideal Option. If your health insurer does not pay your claim, or only pays a portion of your claim, you agree to pay the remaining charges. I authorize Ideal Option, PLLC to disclose to any third-party payor all necessary information and relevant portions of my patient record for the purpose of receiving payment for services rendered