The information given is for the purpose of establishing an account with Eastern Chiropractic and Rehabilitation Center. I understand and agree that health and accident insurance policies are an arrangement between and insurance carrier and me. Futhermore, as a ourtesy to me, Eastern Chiropractic and Rehabilitation Center will assist me in collecting from the insurance company or other entity. I give permission for my medical records to be sent to my insurance company(ies), attorney or to any person representing me. Any amount authorized to be paid by the insurance company(ies) or other intity will be directed to this office and be credited o m account upon receipt of monies. (Reports or forms will be drawn up i accordance with the Inter-professional Relationships: A Guide for Members of the Jefferson county Medical Society and the Birmingham Bar Assoxiation, Appendix A, section 12-21-6.1, (b)(4).) In addition, I understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. This includes any balance due after insurance or othe entity has or has not paid. I understand that if I suspend or terminate my care and treatment, or my case is settled through private, court, attorney, insuranc or self, any fees for professional services rendered me will be immediately due and payable in full within thirty days. I futher consent to any physical examination, radiographic studies, laboratory procedures, chiropractic or adjunctive therapy, or service that is ordered under the general and specific instructions of the doctor. however, for specific conditions of heart, kidney, other internal organs and/or cancer, the Docotr of chiropractis does not undertake, treat or test fot these items. If this is suspected, I will consult a specialist in that given field. Easten Chirpractis and Rehabilitation Center reserves the right to refust treatment to any given party.