Cognitive FX understands that patient's maybe pursuing litigation for their injury, but may not be obtaining treatment through the litigation or guidance of their attorney, and as such, would not like Cognitive FX to contact their attorney through the treatment process, if this is the case, feel free to skip the next question.
If you do fill out the information on the next page, you will be agreeing to the following statement:
I authorize Cognitive FX to release any necessary information including my daily schedule, all records of any treatment, examination, or test results rendered to me or my child during the period of such care, to third-party payers, healthcare practitioners, transportation services, and/or my legal representation. I authorize any benefits through legal litigation or LIEN benefits due to me to be paid directly to Cognitive FX. I agree to be responsible for payment of all services rendered on my behalf or my dependents.