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This includes my deductible and/or copay. I authorize this clinic to furnish to my insurance company all information that may be required in order to process the claims for me and/or my dependents. Please present your insurance card at time of initial appointment. If you do not have your insurance card please fill out the following thoroughly Name of Insurance Address of Insurance Company Policy/ID Group Name of Policy Holder Employer Assignment of Benefits I hereby instruct and direct my...
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