I verify that all information contained in this form is true, correct and complete to the best of my knowledge.

I authorize any health plan, health care provider, health care professional, MIB, federal, state or local government agency, insurance or reinsurance company, consumer reporting agency, employer, educational institution or any other organization or person that has any records of knowledge of my health, has any information available as to diagnosis, treatment and prognosis with respect to any physical or mental condition and/or treatment of me, and any non-medical information about me, to disclose my entire medical record, file, history, medications and any other information concerning me and to give any and all such information to PCT or their authorized representatives, affiliates and subsidiaries.

I understand I have the right to refuse to sign this Authorization without negative consequences as to treatment or plan enrollment, except PCT will not be able to administer claims, determine benefit eligibility or issue payments.

This Authorization is valid for the term of the insurance plan under which a claim has been submitted.

I understand that I have the right to receive a copy of this Authorization upon request and to revoke this Authorization at any time in written communication to PCT.

A copy of this Authorization shall be as valid as the original.

I authorize payment of any benefits for eligible expenses to the provider or other supplier of services which is entitled to payment of the attached bills.