SCHULZE CHIROPRACTIC, LLCDR. RANDALL SCHULZE, DIRECTOR11924 VANCE JACKSON, SUITE 104, SAN ANTONIO, TX 78230PHONE: (210) 696-5150 FAX: (212) 696-3556
Release: I hereby authorize the above stated clinic to release any information acquired in the course of my examination which said insurance company may request.
Assignment: I also assign and request payment of medical benefits to the above stated clinic for medical services. I also understand that I am financially responsible for any changes not covered by insurance.
The following information is needed for our files so we can better serve you as a patient. Please fill in all portions of the form. If you need any help, please ask the receptionist. If your clinic visit is due to an accident, please describe all events associated with it.
WORK RELATED ACCIDENT
I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand and agree that this office will prepare any necessary reports and forms to assist me in making collections from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account upon receipt. I permit this office to endorse co-issued remittances for the conveyance of credit to my account However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable.