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I request that my Insurance carrier s honor my assignment of insurance benefits applicable to the services rendered. I will pay Alexandra Zelenka M. I authorize Alexandra Zelenka M. D. to release information from my medical records to Social Security Administration and/or the Medicare program or its intermediaries or carriers or benefits. If requesting a mailed prescription the office will not be held responsible for non-receipt. INITIAL RELEASE OF MEDICAL INFORMATION AND AUTHORIZATION TO PAY...
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