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Insured Assign Benefits  Form

Insured Assign Benefits Form

Use a Insured Assign Benefits 0 template to make your document workflow more streamlined.

Including Medicare, private insurance and any other health/medical plan, to issue payment check(s) directly to Graystone Family Healthcare for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance. Authorization to Release Information I hereby authorize Graystone Family Healthcare to: (1) release any information necessary to insurance carriers regarding my illness and...
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