In consideration of your undertaking to treat me, I agree to the following:
1. I authorized the release of any and all information you deem appropriate concerning my physical condition and treatment to any insurance company, attorney or adjuster in order to process claims for reimbursement of chiropractic charges incurred by me at Copley Square Chiropractic.
2. I hereby irrevocably authorize the direct payment from the insurance company to Copley Square Chiropractic any sum I owe for my chiropractic treatment in Copley Square Chiropractic.
3. I understand and agree that all chiropractic services rendered me at Copley Square Chiropractic are my responsibility. Any outstanding balance not paid by my insurance company will be paid by myself to Copley Square Chiropractic.
4. I understand that I am responsible for confirming my chiropractic coverage by contacting my insurance company. I understand Copley Square Chiropractic may check general chiropractic benefits on my behalf as a courtesy, but the benefit information provided to me is not a guarantee of coverage or my payment responsibilities. I understand that only my insurance company is responsible for the payment and processing of my claims.