Payment of Benefits toProvider:
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I authorize the release of any medical or other information necessary
to process claims for any services provided for me. I also request
payment of government benefits either to myself or to the party
who accepts assignment. I authorize payment of medical benefits
to the undersigned physician or supplier for all services provided.
I further request and authorize those physicians and authorize
other healthcare professionals who care for me to perform routine
diagnostic procedures and medical treatment as necessary in their
professional judgment.
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