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sa1s3.patientpop.com · US ENSURE THE QUALITY OF YOUR CARE EXCELLENT. WE LOOK FORWARD TO WORKING WITH YOU Name :( Last, First, Ml Patient Information ... orthodontic treatment If
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sa1s3.patientpop.com · smoking, and eating a healthy diet. ... religion, physical handicap, or source of payment. You have the right to treatment for any emergency medical condition
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sa1s3.patientpop.com · Created Date: 6/14/2018 8:57:18 AM
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sa1s3.patientpop.com · Web viewI authorize this practice to submit a claim and, if needed, medical documentation to my insurance company, attorney or other financially responsible
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