Common Contracts
1 similar Registration contracts
REGISTRATIONRegistration • October 27th, 2021
and assign directly to John Carlucci, D.C. all medical 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 to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.
