KM C368-20180308160302 - Chiropractor in Middlesboro, KY · AUTHORIZATION AND RELEASE: I authorize...

5

Transcript of KM C368-20180308160302 - Chiropractor in Middlesboro, KY · AUTHORIZATION AND RELEASE: I authorize...

Page 1: KM C368-20180308160302 - Chiropractor in Middlesboro, KY · AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office.
Page 2: KM C368-20180308160302 - Chiropractor in Middlesboro, KY · AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office.
Page 3: KM C368-20180308160302 - Chiropractor in Middlesboro, KY · AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office.
Page 4: KM C368-20180308160302 - Chiropractor in Middlesboro, KY · AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office.
Page 5: KM C368-20180308160302 - Chiropractor in Middlesboro, KY · AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office.