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.
If a personal representative signs this authorization of behalf of the individual, complete the following:
Your signature is necessary for us to:
I authorize the release of all medical information necessary to process my claims and I authorize the release of this same information, when necessary, to other providers rendering medical/dental care. I assign all medical and surgical benefits, including major medical benefits in which I am entitled, to DR. LYSANDRO TAPNIO. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.
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