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I also authorize Darius J. Karimipour MD PC or insurance company to release any information required to process my claims. Person responsible for bill Is this patient covered by insurance Insurance Name Medicare Yes BCBS Address if different No Medicaid HAP Cofinity/PPOM Contract/Policy Group Subscriber s name Subscriber s S.S. Patient s relationship to subscriber Self Name of secondary insurance if applicable Spouse Child Other Policy IN CASE OF EMERGENCY Name of local friend or...
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