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We Create Healthy Families
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information and certify it to be true and accurate to the best of my knowledge. I consent
to the collection and use of the above information to this office of chiropractic. I
authorize this office and its staff to examine and treat my condition as the doctors see
fit. I hereby authorize the doctor to release all information necessary to any insurance
company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred
by me. I grant the use of my signed statement of authorization with my signature for
required insurance submissions. I understand and agree that all services rendered to me
will be charged to me, and I'm responsible for timely payment of such services. I
understand and agree that health/accident insurance policies are an arrangement between
an insurance carrier and myself. I understand and agree that all services rendered to me
are charged directly to me and that I am personally responsible for payment at the time
services are rendered.
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