Assignment & Release - By signing below, I authorize Quest Chiropractic to release medical records required by my insurance company or companies. I authorize my insurance company or companies to pay benefits directly to Quest Chiropractic and I agree that a reproduced copy of this authorization will be as valid as the original. I understand that I am responsible for any amount not covered by my insurance, or any amount for a patient for which I am the guarantor. I agree that I will be responsible for any collection agency or attorney fees incurred. I understand that by signing below, I am giving written consent for the use and disclosure of protected health information for treatment, payment, and health care operations.

By signing below, I understand the Notice of Privacy Practices; I give my consent for examination and the performance  of any tests or procedures needed. If patient is a minor, by signing I give consent for examination, tests and procedures for the above minor patient.