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Person(s) OK to release appointment or medically related information to concerning you.
*Only applicable if patient is 17 years or younger.
*Only applicable if patient is 17 years or younger.
If different from yourself.
If yes, please specify. If no, please specify with N/A.
If this does not apply, please specifiy with N/A.
If yes, please list with dosage. If no, please specify with N/A.
I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.

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