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I understand that I will be responsible for any payment/deductible not covered by prescriptions are in good standing at the beginning of each treatment month. Any changes that may occur in my insurance coverage. I certify that I have read and understand the above and authorize the initialed consent as of the date below. 3731 SIXTH AVENUE SUITE 103 SAN DIEGO CALIFORNIA 92103 PHONE 619 295-4500 FAX 619 278-0885 DEVELOPMENTAL THERAPY CENTER FINANCIAL AGREEMENT Please initial I hereby authorize...
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