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Patient Demographics Sheet Acrsurgeonscom  Form

Patient Demographics Sheet Acrsurgeonscom Form

Use a patient demographics form 0 template to make your document workflow more streamlined.

Sent to MEDICARE NOT AN HMO or AHCCCS plan. I UNDERSTAND THAT I WILL BE PERSONALLY LIABLE FOR MEDICARE CHARGES IF I AM CURRENTLY ENROLLED IN A MEDICARE or AHCCCS HMO AND HAVE FAILED TO DISCLOSE THIS INFORMATION TO AFFILIATED COLON RECTAL SURGEONS PC. By signing below I authorize the above AFFILIATED surgeon to release any information to any other physician s listed above including my diagnosis and medical records for any treatment/examination rendered. I hereby also grant permission for the...
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