THIS CLINIC DOES NOT MANAGE CHRONIC PAIN. WE DO NOT ENCOURAGE THE LONG TERM USE OF HIGH DOSE NERVE PILLS ( Xanax, Ativan, Valium, etc) "I verify the accuracy of the above information. I authorize the release of any medical information necessary to process any claims. I request payment of claims, and if the payer accepts assignment, I authorize payment directly to the physician or suppler of services described. I realize all charges incurred by myself or my dependents are my financial responsibility, as well as all collection and attorney fees that result from nonpayment"