Common Contracts

1 similar null contracts

REGISTRATION
October 16th, 2021
  • Filed
    October 16th, 2021

and assign directly to Results Chiropractic, LLC all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.

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