Please fill out this form to share with the clinic:
I hereby authorize payment directly to this medical office, for any services rendered to me by the clinicians or any of its authorized agents.
I authorize the release of all medical information to the insured’s health insurance carrier that is:
1) acquired in the course of my examination or treatment and
2) which may have a bearing on the benefits payable under this or any other plan that
provides benefits or services.
I authorize this office or any of his authorized agents to assist me in obtaining payment
from my health insurance companies.
I authorize a copy of this “Signature on File” form to be used in place of the original and that this
copy may be used on all my insurance submissions.