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MEDIGAP AUTHORIZATION Medicare Patients Only MD Inc. for any services furnished me by that provider. FINANCIAL RESPONSIBILITY AND RELEASE OF INFORMATION Patient Name MRN Date I understand that I am financially responsible to Lamia L. Gabal-Shehab MD Inc. for charges not covered by my insurance carrier. I authorize Lamia L. Gabal-Shehab MD Inc. to release to the Social Security Administration or its intermediaries or carriers or other insurance carrier an medical or other information needed...
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I understand that i is a statement or declaration that indicates comprehension or acknowledgment of a specific concept or information.
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