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  •  · 2016. 6. 13. · I am financially responsible for any balances due and authorize the dentists to release any information for this claim. I authorize that my records can be used
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Page 1:  · 2016. 6. 13. · I am financially responsible for any balances due and authorize the dentists to release any information for this claim. I authorize that my records can be used

PATIENT INFORMATION€¦ · I hereby authorize my insurance benefits to be paid directly to my physician. I also authorize the doctor and/or insurance company to release any information

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