Since Last Visit
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About Your Problem
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Authorization and Release
I authorize my insurance benefits to be paid to Brian Cox PT & Chiro (if applicable).
I consent to the release of my diagnostic reports to Brian Cox PT & Chiro.
I will pay for all fees not covered by my insurance.
I agree to email correspondence with Brian Cox PT & Chiro.
I had opportunity to review the notice of privacy practices listed below this form.
I confirm that the information above is accurate and complete.
Confirmation and Signature
The "E-signature" below stands in place of a physical legal signature confirming that I agree to the terms listed under Authorization and Release.
Date of E-Signature