Assignment of Benefits:YES   NO   
I request that payment of authorized insurance benefits be made on my behalf to About Face Ink, LLC dba About Face And Body (hereafter called the organization), 7575 Dr Phillips Blvd., Suite 155, Orlando, Florida 32819, Federal Tax ID # 46-0677404, for any medical tattooing services provided to me.

Authorization to Release Information:   YES   NO      
I authorize the release of any medical or other information necessary to determine these benefits or the benefits payable for related services to the organization, my insurance carrier or other medical entity. A copy of this authorization will be sent to the above-listed insurance carrier. The original will be kept on file with the organization.

Financial Responsibility:    YES   NO           
I understand that I am financially responsible to the organization for any charges not covered by my health care benefits. It is my responsibility to notify the organization of any changes in my health care coverage. I understand I am responsible for the entire bill or balance of the bill as determined by the organization and/or my health care insurer if the submitted claims or any part of them is denied for payment. I understand that by signing this form I am accepting financial responsibility as explained above for all payment for products received.