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Mentally incapable of signing. NOTE: if the patient is a minor, the parent or legal guardian should sign in this section. I authorize the submission of a claim for payment to Medicare, Medicaid, or any other payor for any services provided to me by [SAS] now, in the past, or in the future. I understand that I am financially responsible for the services and supplies provided to me by [SAS], regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to...Show details
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