Medical Arts Obstetrics and Gynecology

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Referring Physician

IN CASE OF EMERGENCY

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Acknowledgment and Consent

I hereby assign my insurance benefits to be paid directly to the undersigned physician. I am financially responsible for any balance or non-covered service. I authorize the physician to release any information required to process my claim.

I have received the HIPAA Notice of Privacy Practices and have been given a copy if requested.

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