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Get Main Street Radiology Patient Waiver And Agreement For Payment 2019

Decided to self-pay even though you may have health insurance that covers these services and waive your right to have the claim submitted to your insurance company on your behalf. The cost of the procedure for which you are agreeing to pay is: Your signature below indicates that you have received a copy of this document and are aware that you are waiving your right to have a claim submitted to your insurance company. Payment is due in full before the procedure is performed..

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