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.
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