All-in-one Foot Care Center

INSURANCE ASSIGNMENT AND RELEASE
I certify that I have insurance coverage with the above insurance company and assign directly to All-in-One Foot Care Center all insurance 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 authorize the use of my acceptance on all insurance submissions. All-in-One Foot Care Center may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the submission date of this form.