I hereby give Vallejo Foot & Ankle Clinic (VFAC) permission to render examination and treatment of my foot conditions. I request that payment of medical benefits be made to VFAC on my behalf for any services furnished to me. I authorize the release of medical information to those agents requesting any information needed to determine these benefits payable for related services. Furthermore, I realize that by signing this form, I agree to pay for any services rendered that are denied or not covered by my insurance company.
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