I understand that the information that I have given today is correct to the best of
my
knowledge.
I also understand that this information will be held in the strictest of confidence
and
it is my
responsibility to inform
the office of any changes in my medical status.
I hereby authorize the release of any information pertaining to my medical treatment
necessary to
process any insurance claims. I further authorize the application for benefits on my
behalf for
covered services and
payment of any benefits to the office. I understand that I am responsible for any
amount
not
covered by insurance.
I understand that where appropriate, credit bureau reports may be obtained.