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Initial here 3. I authorize Lisa A. Perryman M. D. P. C. to file charges with my insurance carrier and I assign payment of medical benefits to Lisa A. I understand that Lisa A. Perryman M. D. P. C. will file charges directly with my insurance carrier and that my copayment is due on the date of service. Perryman and providers of Lisa A. Perryman M. D. P. C. to treat the patient identified above. I acknowledge that I am responsible to pay all charges for all treatments administered by the...

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