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Available Forms

Patient Registration

Insurance Information

MEDICAL INFORMATION

By typing my 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 our Notice of Privacy Practices, available on our website and in the office), and as necessary to process insurance claims. I authorize payment of medical benefits to the practice. I understand that I am responsible for co-pays, deductibles, and any amount not covered by insurance, as per the Notice of Financial Policy, available on our website and in the office.

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