Patient Registration
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  • ###-##-### Format
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  • Primary Insurance
  • Secondary Insurance
  • * Required by HIPAA

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  • Assignment of Benefits

    I, the undersigned, hereby authorize the release of any information relating to all claims for benefits submitted on behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits, for services rendered or for service to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or dependents, and that I will be bound by this signature as though the undersigned had personally signed the particular claim.
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