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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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