Insurance Information & Assignment Authorization

I agree to provide DSSR with relevant information and referral forms necessary for treatment or payment prior to seeing the Doctors and I hereby assign DSSR to receive payments from insurance companies or negligent parties.

Payments are payable to:

I authorize DSSR to release any relevant information to any insurance company, adjustor or attorney who will assist in the processing and payment of my claim.

I fully understand and agree insurance policies are an arrangement between an insurance carrier and myself. I will be responsible for any expenses not paid by insurance.

A photocopy of this form shall be as valid as the original.

I acknowledge I was offered a copy of DeFabio Spine & Sports Rehab's Notice of Privacy Practices, with complete understanding and I had all my questions answered to my satisfaction.

I may receive assessment and treatment in a private room or an open therapy suite and every attempt will be made to speak in a discreet conversational level.