I certify that I, and/or my dependent(s), have insurance coverage with the above insurance company, and assign directly to Dr. Son Nguyen, DC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The Doctor(s) may use my health care information and 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.