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  • New Patient Demographics and Insurance Info

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  • Guarantor Information

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  • Consents

  • By signing below, I acknowledge that I have reviewed the NOTICE OF PRIVACY PRACTICES from Associated Endocrinologists/MHP available on their website http://www.endocrinemds.com

    I hereby authorize my insurance benefits to be paid directly to Associated Endocrinologists, realizing I am responsible to pay non-covered services as well as an assignment of the right to pursue payment, other alleged ERISA violations, and the right to pursue all courses of action, including, but not limited to the right to pursue payment and other ERISA claims.

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