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· PDF fileWELCOME TO OUR OFFICE - Signature File for Billing: I authorize release of this form on all my insurance submissions. *** authorize release of information to all my

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Page 1: · PDF fileWELCOME TO OUR OFFICE - Signature File for Billing: I authorize release of this form on all my insurance submissions. *** authorize release of information to all my
Page 2: · PDF fileWELCOME TO OUR OFFICE - Signature File for Billing: I authorize release of this form on all my insurance submissions. *** authorize release of information to all my
Page 3: · PDF fileWELCOME TO OUR OFFICE - Signature File for Billing: I authorize release of this form on all my insurance submissions. *** authorize release of information to all my
Page 4: · PDF fileWELCOME TO OUR OFFICE - Signature File for Billing: I authorize release of this form on all my insurance submissions. *** authorize release of information to all my
Page 5: · PDF fileWELCOME TO OUR OFFICE - Signature File for Billing: I authorize release of this form on all my insurance submissions. *** authorize release of information to all my

AND COSMETIC SURGERY PATIENT · PDF filePOS® Reorder # 1011567 RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS I authorize the release of medical information to my primary care

AND COSMETIC SURGERY PATIENT · PDF filePOS® Reorder # 1011567 RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS I authorize the release of medical information to my primary care

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