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This balance is payable at the time of service or upon receipt of statement. Acknowledgement of Receipt of Notice I have received the Notice of Privacy Practices provided by Willem Verweij Physical Therapy LLC. Assignment of Insurance Benefit Medicare included and Release of Information I authorize and request payment of medical benefits directly to Willem Verweij Physical Therapy LLC. I understand that the terms of this notice may change and I may receive a copy of a revised notice by...
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