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Patient will be responsible for any and all deductibles copays and coinsurance not covered by the insurance carriers for all in-network and out of network carriers. Medicare will cover up to 80 of allowable charges after your deductible is met. Please make sure that you have the rollover program Medicare provides. Patient/Guardian Printed Name Signature Date Patient Policies and Consent for Assessment and Treatment Procedures Payment is due at the time of service this includes all copays...
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