Please answer the following
I hereby give permission to Dr. Jeremy M. Thomas and associates to administer treatment and perform such procedures as may be deemed necessary in the diagnosis and / or treatment of the extremity condition. I also, herby assign to the above-named physician all benefits provided by my insurance company policy or policies for medical or surgical care.
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By signing you fully understand your rights and responsibilities.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
I have received a copy of the Notice of Privacy Practices.
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We were unable to obtain a written acknowledgement of receipt of the Notice of Privacy Practices because:
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