Common Contracts
1 similar Patient Registration and Insurance Assignment Agreement contracts
Patient Agreement:Patient Registration and Insurance Assignment Agreement • August 7th, 2018
and assign directly to Theriault Chiropractic 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.
