PATIENT INFORMATION

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INSURANCE INFORMATION

Under whose name is your insurance?

PATIENT CONFIDENTIALITY

Patient confidentiality is of great concern to our office. Please indicate below with whom our office may speak or leave a message with regarding your health, medication, test results, etc.

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PATIENT AGREEMENT

Should inaccurate or omitted insurance information be supplied causing a reduction or non-payment of benefits, the obligation of payment will be transferred to the responsible party. I hereby authorize the release of any medical information for the processing of insurance. I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled to Advanced Gastroenterology Group. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. 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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