I hereby authorize Colleyville Chiropractic to bill my insurance carrier(s) directly for services rendered. I assign all insurance benefits due for services provided to Colleyville Chiropractic. I understand that I am financially responsible for any amount not covered by insurance.

I authorize Colleyville Chiropractic to release any medical information necessary to process claims for payment and to communicate with other healthcare providers involved in my care.

I understand that I am responsible for payment of all services rendered, regardless of insurance coverage. I agree to pay all charges not covered by my insurance, including co-payments at time of service.

I acknowledge that I have been offered a copy of Colleyville Chiropractic's Notice of Privacy Practices, which describes how my health information may be used and disclosed.