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Facesheet 2018 - OBGYN Alaska€¦ · Financial Agreement, Authorization for Treatment, & HIPAA Notice I authorize treatment of the person named above and agree to full responsibility

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Page 1: Facesheet 2018 - OBGYN Alaska€¦ · Financial Agreement, Authorization for Treatment, & HIPAA Notice I authorize treatment of the person named above and agree to full responsibility
Page 2: Facesheet 2018 - OBGYN Alaska€¦ · Financial Agreement, Authorization for Treatment, & HIPAA Notice I authorize treatment of the person named above and agree to full responsibility
Page 3: Facesheet 2018 - OBGYN Alaska€¦ · Financial Agreement, Authorization for Treatment, & HIPAA Notice I authorize treatment of the person named above and agree to full responsibility
Page 4: Facesheet 2018 - OBGYN Alaska€¦ · Financial Agreement, Authorization for Treatment, & HIPAA Notice I authorize treatment of the person named above and agree to full responsibility
Page 5: Facesheet 2018 - OBGYN Alaska€¦ · Financial Agreement, Authorization for Treatment, & HIPAA Notice I authorize treatment of the person named above and agree to full responsibility
Page 6: Facesheet 2018 - OBGYN Alaska€¦ · Financial Agreement, Authorization for Treatment, & HIPAA Notice I authorize treatment of the person named above and agree to full responsibility
Page 7: Facesheet 2018 - OBGYN Alaska€¦ · Financial Agreement, Authorization for Treatment, & HIPAA Notice I authorize treatment of the person named above and agree to full responsibility