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Signature of Patient/Responsible Party Date Witness Signature Date Revised 05/01/2014 Notice of Privacy Practices This notice describes the privacy practices of the Nebraska Neurosurgery Group. Please read carefully. I also request payment of benefits to my Provider when he accepts assignment. I also understand I am financially responsible to The Nebraska Neurosurgery Group LLC for any amounts not covered by my course of treatment. We use encryption practices to insure the integrity and...

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