I certify that the above information is correct. I understand that I am personally responsible to pay all charges for services rendered to me and agree to make payment, when due. Any billing sent by the provider to an insurance company, attorney, or other third party is for the accommodation of the patient and does not relieve the undersigned to pay charges for services provided. If it is determined by the Worker’s Compensation Board that the illness or condition is not a result of a compensable Worker’s case, I agree to pay Springer Physical Therapy, LLC for services rendered. I authorize payment for these services be paid directly to Springer Physical Therapy, LLC.