Add Secondary Insurance
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and its agents any information needed to determine benefits payable for related services. This authorization is in effect for my lifetime, or until I choose to revoke it.
We are asking for your race and ethnicity because some people have higher risks of developing certain diseases.
We will keep this information confidential (private) and will update it in your medical record. This information will assist us in continuing to provide you with the best health care.
Please fill in the information below. We greatly appreciate your participation.
If you have other children, you may include them below
Add Patient Name
to seek medical care and treatment for him/her/them
My signature below certifies my consent for examination and treatment of my children.
This consent is valid for one year from date of signature.
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