I understand and agree that health and accident insurance policies are an agreement between my insurance company and me. Smith Chiropractic Office will prepare any necessary forms to assist me in making collections from the insurance company. Any amount authorized will be paid directly to this office and credited to my account upon receipt.

Certification of insurance is not a guarantee of payment from the insurance company. I am ultimately responsible for any amount not paid by the insurance company, unless my insurance states otherwise.

All services rendered to me are charged directly to me and I am personally responsible for payment. If I suspend or terminate my care and treatment, any fees for professional services rendered become immediately due and payable at regular standard fees. If my account becomes delinquent and an attorney's assistance or a lawsuit is necessary to collect, I am responsible for any and all fees necessary for collection. I understand a finance charge of 1.5% (18% annually) will be charged on balances after 60 days.

The purpose of chiropractic care at this office is the detection, location, and correction of the vertebral subluxation that produces nerve interference on the brain stem and/or spinal cord nerves. With proper nerve supply restored through the chiropractic adjustment, the body can begin the process of repair leading to health. If we encounter unusual non-chiropractic findings during care, you will be encouraged (if you desire) to seek advice and diagnosis from a health care provider who specializes in that area. I accept chiropractic care on this basis alone.

AUTHORIZATION TO PAY DIRECTLY TO PROVIDER: I authorize payment of insurance benefits to be paid directly or by two-party checks to the provider listed above. Please make checks payable to Dr. Roger D. Smith.