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AUTHORIZATION FOR TREATMENT AND ACKNOLEDGEMENT OF FINANCIAL RESPONSIBILTY I hereby authorize all parents guardians family members and caretakers listed above to accompany the above named patient to office visits at Margiotti Kroll Pediatrics P. I certify that myself/my dependent s have health insurance coverage as indicated above. I hereby authorize Margiotti Kroll Pediatrics P. Margiotti Kroll Pediatrics P. C. reserves the right to apply a billing fee for all co- payments that are not...

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