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Insurance
ASSIGNMENT AND RELEASE
I, the undersigned, certify that I (or my dependent) have insurance coverage with
and assign directly to Chiropractic Office all insurance 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(s) to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
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