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In the event that I do not have insurance I understand that I am responsible for payment of all services rendered. Revised 2/2016 HCM. I authorize my insurance carrier to pay the provider for the services rendered. In the event that payment is made to the policyholder I agree to submit payment to CCHCI immediately. I understand I am responsible for all co-payments coinsurance deductibles and out-of-pocket deemed to be my responsibility by my insurance plan. I understand that I am required to...
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