AUTHORIZATION AND RELEASE:

I authorize payment of insurance benefits directly to the provider or clinic. I authorize my provider to release all information's necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that i am responsible at all cost of medical care, regardless of insurance coverage. I also understand that if i suspend or terminate the schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.