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Patient Registration Form

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Insurance Authorization and Assignment

I hereby authorize the provider in this practice to furnish information to my insurance carrier concerning my illness and treatments and I hereby assign to them all payments for medical services rendered. I understand that I am financially responsible for payment at the time of service for any amount not covered by my insurance. This assignment shall remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. 

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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