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Get UIHC A&A - Authorization To Bill Insurance (Release Of Information And Payment Request) 2019-2024

Rance (Release of Information and Payment Request) Patient Name Birth Date A. Insurance, Payment Information and Assignment of Benefits: I request the University of Iowa Hospitals & Clinics (UIHC) and/or its affiliates and the Faculty Practice Plan to submit claims on my behalf to my insurance company, Medicare, or other third party payor for my care and authorize disclosure of health information to the extent necessar.

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