CURRENT PATIENTNEW PATIENT
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INSURANCE PAYMENT AUTHORIZATION AND RELEASE: I hereby authorize my insurance benefits to be paid directly to Choices Women’s Medical Center, and acknowledge that I am financially responsible for any unpaid balance. I also authorize Choices Women’s Medical Center to release any information required by my insurance company. I know it is a crime to fill out this form with facts I know to be false or to leave out facts I know are important.
PERMISSION TO TREAT: I hereby give Choices Women’s Medical Center permission to evaluate and treat the above named patient.
(BY ENTERING YOUR NAME HERE, YOU ARE COMPLETING A DIGITAL SIGNATURE)(required)
Signature Date: (required)
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