I, the undersigned certify that I (or my dependent) have insurance coverage with the above
stated insurer. I assign directly to Saluja Medical Associates all insurance benefits, if any,
otherwise payble to me for the services rendered. I understand that I am financially
responsible for all charges whether or not paid by insurance. I hereby authorize the
physician to release all necessary information to secure the payment of benefits. I authorize
the use of this signature on all insurance submissions.
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