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English Spanish Other PATIENT ETHNICITY Select one. Hispanic or Latino Non-Hispanic or Non-Latino PATIENT RACE Select one or more. I also authorize Galen Medical Group PC to utilize a fax machine to transmit any or all of the above medical records pertaining to my medical care or insurance reimbursement. I understand that I am financially responsible for deductible amounts co-payments co-insurance amounts non-covered charges and any and all balances not covered under a contractual...
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