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Page 2 of 3 MLR V4 9. 1. 2016 all rights reserved. PATIENT AGREEMENT Patient has read all the above and understands and agrees to honor all terms and conditions of this Medical Lien contract. Dr. Ryan D. Kauffman 1136 Jacklin Rd. Milpitas CA 95035 Phone/Fax 408 262-1371 MEDICAL LIEN AGREEMENT PATIENT NAME DATE OF INJURY/INCIDENT INSURER/ADJUSTER CONTACT INFO CASE /COURT LATER ADD IF NEEDED The named Patient Patient desires medical treatment by the below-named Provider including all entities...
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