Release of Information: I authorize the physician(s) to release any information acquired during my examination or treatment.
I understand that I am directly & fully responsible to Dr. Ronald M. Repice, D.C. & Rejuvenations for Chiropractic / Medical Services rendered and that this agreement is solely made for Dr. Repice and Rejuvenations additional protection and in consideration of his awaiting payment. Should Collection procedures become necessary, for any reason, to collect the amount due Rejuvenations & Dr. Repice for your treatment, additional charges for attorney’s fees & interest will be added to the balance owed for treatment.
I further understand that such payment is not contingent on any settlement, insurance payment, including the balance remaining after payment of possible insurance benefits, judgment, or verdict by which I may eventually recover said Chiropractic / medical Services.
MEDICARE PATIENTS ONLY: Dr. Ronald M. Repice, II, D.C. and Rejuvenations has advised me that some services provided by this office may not be reimbursed by Medicare. Should Medicare deny payment for any of the services provided, I have advised Dr. Repice that I shall be personally responsible for payment to the doctor.