A Smile 4 U - Logan Honeycutt

I authorize the use of my signature on all insurance

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Unformatted text preview: insurance. I authorize the use of my signature on all insurance submissions. A Smile 4U may use my child’s health care information and may disclose such information to the above-named insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. ___________________________________________________________________ Signature of Parent, Guardian or Personal Representative ___________________________ Date Rebekah Naomi Diaz ___________________________________________________________________ ____________________________ Please print name of Parent, Guardian or Personal Representative Date PLEASE COMPLETE BOTH SIDES...
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