Authorization and Release

Please check any and all insurance coverage that may be applicable in this case.

□Major Medical          □Worker's Compensation          □Medicaid          □Medicare    □Auto Accident          □Other

Name of Primary Insurance Company                                                                                

Name of Secondary Insurance Company (if any)                                                              

AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.

The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.  If there is anyone you do not want to receive your medical records, please inform our office.

Patient's Signature                                                                                         Date               
Guardian's Signature Authorizing Care                                                       Date