Registration Form

Michael Taymor, MD

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Insurance

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(Not Living in Same Household)

Disclaimer: 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.

(Parents/Guardian)

I give consent for treatment and authorize that my insurance benefits for covered services be paid directly to Michael Taymor, M.D. I understand that I am financially responsible for any balance or service not covered by my insurance company. I authorize Dr. Taymor’s Office and/or the insurance company to release any information required to process my claim. I also authorize a copy of this Consent to be used in lieu of the original. I further authorize the release of private health information to other providers involved in my child’s care.

Disclaimer: 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.

(Parents/Guardian)

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