I hereby authorize Goffstown Chiropractic Care, PLLC to release healthcare and financial data to my insurance carrier(s) and attorney(s). I also authorize Goffstown Chiropractic Care, PLLC or its chosen representative to contact me at my home or work by telephone, fax, text message or e-mail concerning appointment times and scheduling, diagnostic testing results, electronic invoicing and other information pertinent to my care at this office.The undersigned hereby accepts full financial responsibility for charges and services rendered to the patient. The undersigned understands that services are rendered and charged to the patient and not to the insurance carrier(s). Goffstown Chiropractic Care, PLLC cannot accept total responsibility for collecting an insurance claim or for negotiating a disputed settlement. The undersigned also agrees that this obligation shall exist regardless of private contractual agreement between the patient and any insurance carrier, attorney or third party payor not signing this agreement. Financial responsibility will also include charges and services not covered by insurance for which payment is denied through any utilization review or precertification procedures.Consent is hereby given by the undersigned for chiropractic treatment and diagnostic studies as ordered by Goffstown Chiropractic Care, PLLC and performed by its technical staff. The undersigned states that he/she is the patient’s parent or legal guardian.I hereby irrevocably authorize payment of the chiropractic benefits otherwise payable to me to be made payable and mailed directly to Goffstown Chiropractic Care, PLLC for professional services rendered. NO OTHER THIRD PARTY, including my attorney, should receive payment of my bills except this office for the remainder of this claim. It will be assumed and relied upon that the insurance carrier has agreed to and acknowledges chiropractic coverage and will send payments directly to this office.I irrevocably assign to Goffstown Chiropractic Care, PLLC, the right to payment for chiropractic services provided to the patient by Goffstown Chiropractic Care, PLLC out of (i) any applicable medical payments coverage; and (ii) any monetary recovery from a legally liable party, whether by settlement or by verdict. In order to effectuate such assignment, I agree to sign any and all documents necessary to effectuate this assignment, including, without limitation, a letter to any attorney representing me in the form provided by Goffstown Chiropractic Care, PLLC.This is to confirm that I have received a copy of this office’s Notice of Privacy Practices. I understand that I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to conduct, plan and direct my treatment, obtain payment from third party payors and conduct normal healthcare operations such as quality assessments and accreditation.I have been informed that it is not uncommon that patients have some increased discomfort after an adjustment. If that happens I will apply ice to the area and rest it. If I am concerned about this discomfort or develop any new symptoms I will call the doctor immediately. If I am out of town or unable to contact the doctor, I can present myself to the emergency room.If any tests were performed outside of this office (laboratory or other diagnostic procedures) I understand that the doctor will notify me of the results at my next scheduled appointment.I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physiotherapy and, if necessary, diagnostic x-rays, on me by the doctor and/or any of his or her qualified staff.I will have the opportunity to discuss with the doctor the nature and purpose of chiropractic adjustments and other procedures relative to my care. I understand that the results are not guaranteed.I further understand and am informed that, as in all health care, in the practice of chiropractic there are some very slight risks with treatment, including, but not limited to muscle strain and sprain, disc injury and cerebrovascular accident. I do not expect the doctor to be able to anticipate and explain all the risks and complications and I wish to rely on the doctor to exercise his or her best judgment during the course of the procedure which, based upon the facts then known, the doctor feels at the time is in my best interest.