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Group Name of Policy Holder Patient s Relationship to Policy Holder Self Spouse Child Other Policy Holder s Date of Birth Secondary Insurance I hereby authorize the release of medical information to insurance carriers and/or other physicians and also for benefits to be paid directly to Virginia Physicians For Women Ltd. Should this account become delinquent I agree to pay all collection and court costs including attorney s fees which are 31 of the total balance owed. Guarantor Signature...
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