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I authorize release of my medical financial records to individuals as delineated in Ladies First Obstetrics Gynecology of Dothan Inc. s Notice of Privacy Practices. On any unpaid balance I assign benefits due from any insurance company or third party to Ladies First Obstetrics Gynecology of Dothan Inc. I understand that payment is due on the date service is received and I will be responsible for payment. NEW PATIENT PAPERWORK ACCOUNT Date Welcome to Ladies First Obstetrics Gynecology of...
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