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Patient Financial Information Sheet

  • I understand that payment is due in full at time of service unless other arrangements have been made.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • I authorize the release of any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such care to third party payers and/or other health practitioners.

    I authorize and request my insurance company to pay directly to the doctor insurance benefits otherwise payable to me.

    I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

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