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									                       Health Insurance
Name:

Billing Address:
            Street Address

            City                   State                 Zip
Code
Phone:

Date of Birth:

Employer:

Subscriber Name (if different):                     Date of
Birth:

Subscriber Employer:

Insurance Company:

Identification Number:

Group Number:

Relationship to Insured (Self, Spouse, Child):

Name of Referring Physician:

Physician Phone Number:

Please Read and Sign the Following:
I acknowledge that the above information   is complete and
accurate to the best of my knowledge and   I will notify Sue
Wozniak, LMP, if any changes occur in my   physical condition
prior to treatment, or any changes occur   in the information
as presented on this form.

I agree to the release of information for medical and/or
insurance purposes and authorize Sue Wozniak to obtain any
information from my healthcare providers concerning my
health.

I,___________________________________ , give Sue Wozniak,
LMP, permission to bill my health insurance company for
services provided. I am aware that I am fully responsible
for all health care bills for services rendered and that
payment is not contingent on any settlement, judgment or
insurance payment. I agree to pay for services rendered if
my insurance company fails to pay.

Signature                          Date

								
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