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***PLEASE FILL OUT BOTH SIDES AND PLEASE SIGN AND DATE ATTACHED SHEET FOR THE BILLING AND COLLECTION POLICES*** I understand that, under the Health Insurance Portability & Accountability Act of 1996

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Anyone who is requested to fill out the form that specifically states "please fill out both" needs to follow these steps mentioned above. The phrase "please fill out both" implies that there are two parts or sections that require completion, and it is essential to fill out both sections accurately. Whether it is an individual, organization, or any other entity, anyone who receives this instruction on a form needs to ensure that both sections are properly filled out.

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Individuals or entities specified by the form instructions.

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Details as outlined in the form guidelines.

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