I hereby acknowledge receipt of services provided by Comp-X or its affiliated companies and authorize payment of any workers' compensation, no-fault, liability, or other applicable insurance benefits for services provided by Comp-X and its affiliated companies to be made directly to Comp-X.

I authorize Comp-X to use, disclose, and obtain my health and personal information as necessary to coordinate services, process claims, secure payment, and conduct healthcare operations as permitted by applicable law, including HIPAA. I further authorize healthcare providers, employers, insurers, claims administrators, attorneys, and other parties involved in my claim to release information necessary for these purposes.

I acknowledge that I have been notified of Comp-X's Notice of Privacy Practices, available at www.compxmedical.com.