Thank you for choosing Advanced Gastroenterology Group for your medical needs. We are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our financial policies.
By my signature below, I hereby authorize assignment of financial benefits directly to Advanced Gastroenterology Group. I understand that I am financially responsible for charges not covered by this assignment. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
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