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Insurance Authorization Form
6Questions
  • 1
    (Under whose name is the insurance held)
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  • 2
    (Under whose name is the insurance held)
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  • 3
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  • 4
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  • 5

    By signing this form:

    • I authorize the release of any medical or other information necessary to process claims on my behalf.
    • I authorize payment of government or commercial medical insurance benefits to The Resilience Group.
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  • 6
    Clear
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