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Insurance File Release Authorization
Insurance File Release Authorization
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$2.60
Default Title - $2.60 USD
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This item is a recurring or deferred purchase. By continuing, I agree to the
cancellation policy
and authorize you to charge my payment method at the prices, frequency and dates listed on this page until my order is fulfilled or I cancel, if permitted.
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PI/Auto Accident Form patients will sign giving your office permission to inquire about their Medical payments coverage on their policy.
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