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INSURANCE
RELEASE AND ASSIGNMENT
TO MY INSURANCE CARRIER(S):
I authorize the release of any medical information necessary to process my insurance claim(s).
I authorize and request payment of medical benefits directly to my physicians.
I agree that this authorization will cover all medical services rendered until such authorization is revoke by me.
I agree that a photocopy of this form may be used in lieu of original
I agree to pay any balance that is not covered by my insurance company.
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