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Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. THANK YOU FOR YOUR COOPERATION. DATE X SIGNED Patient or parent if under 18 years of age PREMIERMEDICALHV. I also Name Signature Date RECORDS RELEASE AUTHORIZATION This record release authorization allows us to obtain and/or release your records to and from your primary physician and other physicians you are under the care of. Physician/Hospital Address Phone number ADVANCED DIRECTIVES Yes No...
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