Please print this form using the print function of your browser.  You can then sign the form and bring it with you to your first appointment. This form will not be submitted via the Internet, so security is not an issue.

I have read and understand the payment policy of BACK AND NECK PAIN CENTER.  I understand that my insurance is an arrangement between myself and my insurance company, NOT between BACK AND NECK PAIN CENTER and my insurance company.  I request that BACK AND NECK PAIN CENTER prepare the customary forms so that I may obtain insurance benefits.  I also understand that if my insurance does not respond within 60 days, or if I suspend or terminate my schedule of care as prescribed by the doctors at BACK AND NECK PAIN CENTER that fees will be due and payable immediately.  ALL LEGAL AND COLLECTION FEES WILL BE ADDED TO THIS DEBT!

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Patient's signature (or guardian if patient is a minor)     Date

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Witness