Assignment of Benefits

Assignment of Benefits

Financial Responsibility

All professional services rendered are charged to the patient and are due at the time of service, unless other arrangements have been made in advance with our business office. Necessary forms will be completed to file for insurance carrier payments.

Assignment of Benefits

I hereby assign all medical benefits, including major medical benefits to which I am entitled. I hereby authorize and direct my insurance carriers), including private and auto insurance and any other health/medical plan, to issue payment check(s) directly to D.r Anthony Rayman / KeyStone Chiropractic for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance. Al payments for my services can be made payable to:

Dr. Anthony Rayman

KeyStone Chiropractic

3001 I Street, Suite 115

Sacramento, CA 95816

Authorization to Release Information

I hereby authorize Dr. Anthony Rayman to: (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated in the course of examination and treatment; and (3) allow a photocopy of my signature to be used to process insurance claims for the period of a lifetime. This order will remain in effect until revoked by me in writing.

I have requested medical services from Dr. Anthony Rayman on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.