Our email with NOT be given
to thirds parties, only used
for office communications
We will try to verify your insurance coverage, based on the information provided, prior to the time of your appointment to better assist you.
*If an auto accident, please provide:
Signatures (Will be obtained when you come for your appointment)
I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment.
I hereby authorize Sunrise Chiropractic Group, Inc. to release my medical information to my health insurance company, automobile insurance company, or any other insurance company providing medical coverage benefits to me for the completion of my insurance form(s). I also hereby authorize and request payment of any medical/chiropractic benefits to which I may be entitles from my insurance policy, including automobile personal injury protection, be made payable to and forwarded to Sunrise Chiropractic Group, Inc 25300 Borough Park Drive, Suite B, Spring, Texas 77380.
Patient's signature _______________________________________________
Spouse's or guardian's signature __________________________________