Step 1 of 9

  • Introduction

    I hereby consent to a chiropractic evaluation and examination, x-ray(s), chiropractic treatment(s), decompression, k-laser, supplements, healthy lifestyle information (books, CD’s, DVD’s etc), or activities of daily living information rendered to the client which our doctors may consider or advise in the treatment of my case and guarantee payments of the charges incurred. I hereby assign and authorize payment of insurance benefits directly to Stanlick Chiropractic. I hereby authorize the above named doctor(s) to release information requested on this form and I further authorize release of any and all medical records or other pertinent information necessary to obtain payment. I know I am responsible for payment of my account and I understand and agree that I am ultimately responsible to ensure that all services needing pre-authorization by my insurance company are pre-authorized and that any balances for denied services, deductibles, coinsurance and co-pays are my responsibility to pay.