The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Brixton Chiropractic and Acupuncture, insurance company, adjuster, or attorney involved in this claim to release any information required to process my claims. I give consent to the doctor and his/her staff to administer treatment and perform such procedures as deemed necessary in the diagnosis and treatment of named patient.