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I authorize the use of this signature on all insurance submissions. 1124 S. Lake Fort Worth TX 76104. Bill Hanna D. D. S. and may be declined at any time at which prompt payment for the remaining balance is required by me the patient. I also give permission for Dr. Bill Hanna D. D. S. and his dental team to use my radiographs study models and/or photograph for in-office patient education. I consent to the use and disclosure of my protected health information to obtain payment information in...
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