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To the following risks a The Health Insurance Portability and Accountability Act of 1996 HIPAA recommends that E-mail 2. Com AUTHORIZATION TO CHARGE DEBIT/CREDIT CARD Cardholder Name Date of Birth Phone Street Address City State Zip CREDIT CARD Visa or MC only EXP. This agreement will expire after treatment is terminated and no further charges are incurred. Cardholder Signature Cardholder Printed Name PATIENT EMAIL AND TEXT MESSAGE CONSENT FORM copy. If you are unable to reach your Thrive...
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