Get the free Page 3 - Fill out Payment of Benefits Authorization/Records Release
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Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount co-insurance or any other balance not paid for by your insurance. If your insurance requires a written referral from your physician and you do not obtain one prior to your visit or procedure you will be responsible for payment for Services rendered. COPAYMENTS ARE EXPECTED AT THE TIME SERVICES ARE RENDERED. I also Name Signature Date...
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