Patient Registration and Insurance Assignment Agreement Sample Contracts

REGISTRATION

Patient Registration and Insurance Assignment Agreement • February 13th, 2022

• Contract Type
  Patient Registration and Insurance Assignment Agreement
• Filed
  February 13th, 2022

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.

REGISTRATION

Patient Registration and Insurance Assignment Agreement • May 16th, 2022

• Contract Type
  Patient Registration and Insurance Assignment Agreement
• Filed
  May 16th, 2022

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.

Patient Agreement:

Patient Registration and Insurance Assignment Agreement • August 7th, 2018

• Contract Type
  Patient Registration and Insurance Assignment Agreement
• Filed
  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.