West Coast Spine Center.
Craig L. Barcomb, D.C.

I voluntarily consent to receive medical and health care services that may include diagnostic procedures, examination and treatment. I hereby assign, transfer and set over to West Coast Spine Center all of my rights, title and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am financially responsible for all charges whether or not they are covered by Insurance.

I certify that I have read this form and understand its contents.