Plaza Infectious Disease, PC


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Authorization/Assignment/Release of Information
I hereby assign all medical and/or surgical benefits to which I am entitled, including Medicare, private, HMO/PPO, and commercial insurances as well as third party payors, be made on my behalf to Plaza Infectious Disease, PC for any services furnished to me or my family by Plaza Infectious Disease, PC. I hereby authorize said assignee to release all information necessary, including Medical Records, to secure payment or for determination of benefits payable for related services. A photocopy of this assignment is to be considered as valid as the original.
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