To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my Doctor if I or my children ever have a change in health.
**I certify that I. and/or my dependent(s) have insurance coverage with And assign directly to Dr. Beckman all insurance benefits if any. Otherwise payable to me for services rendered. I understand that I am financially responsible for all changes whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. *The above-name doctor may use my health care information man may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the dated signed below. **