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Dear Patient; Please initial each item below where there is a blank line that you have read and understand our office policy regarding the payment of amounts that are the responsibility of the patient: For
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Read the instructions carefully to understand the purpose and requirements of each item.
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Begin by placing your initials in the designated space for each item.
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Make sure to use your full initials and ensure they are legible.
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Double-check that you have initialized all the required items and haven't missed any.
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Each item must be initialed by the person completing the form.
The person responsible for completing the form is required to file each item.
Each item should be initialed by the person completing the form.
The purpose is to ensure that each item has been reviewed and approved.
Each item should contain relevant information related to the form.
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