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Unformatted text preview: their insurance. If they chose to continue with care in the facility they must be willing to cover these charges. Service to be performed: __Prenatal Care Estimated charge: __$1000.00__________ Date of planned service: _____October 24, 2010 _____ Reason for exclusion: _Prenatal care is not covered under insurance _ I, __Fernandez-Valle Nancy , a patient of _Dr. Ross _, understand the service described above is excluded from my health insurance. I am responsible for payment in full for this service. Service to be performed: __Delivery __ Estimated charge: ____$1,300.00 Date of planned service: November 18, 2010 ______ Reason for exclusion: _Delivery is not covered under insurance. I, _Fernandez-Valle Nancy _, a patient of _Dr. Ross, understand the service that is described above is excluded from my health insurance. I am responsible for payment in full....
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- Fall '10
- Credit card