Tomball Health Care For Pediatrics
I hereby authorize Tomball Healthcare for Pediatrics, P.A. to release any medical Information claims relating to the medical care rendered by Tomball Healthcare for Pediatrics, P.A..
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I authorize payments of medical benefits to Tomball Healthcare for Pediatrics, P.A. for any medical care rendered to myself or to my dependents. I understand that I am responsible for any amount not covered by my insurance.
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