Signature on file Chiropractic, Massage, Trigger Point Therapy, Salt Cave and more!Let us help you achieve your health goals! BOOK AN APPOINTMENT Signature on file Leave this field blank Dr. Janine D. Kelly (optional) 1762 Newbridge RoadBellmore, NY 11710 SIGNATURE ON FILE I authorize the use of this form on all my insurance submissions. I authorize release of information to all my insurance Companies. I understand that I (as the patient) ultimately responsible for my bill. I authorize my doctor to act as my agent in helping me obtain payment from my insurance company. I authorize payment directly to my doctor. I permit the copy of this authorization to be use in place of original. Date Signature Start Drawing Clear Done Start Over Send
