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Patient Registration

Insurance Information

MEDICAL INFORMATION

By typing by name below, I verify that the information submitted is correct. I authorize the release of medical information to my referring provider, to consultants if needed (subject to HIPAA Privacy policy, link above and made available in the office), and as necessary to process insurance claims. I authorize payment of medical benefits to the physician. I understand that I am responsible for co-pays, deductibles, and any amount not covered by insurance.

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