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Ble areas of the claim form. 2. Sign the claim form. 3. Fax this form to expedite your claim retain original for your records. The following section must be completed and signed by the employee/patient. Occupation Any fee for the completion of this form is the patient s responsibility. Social Security # Employer MUST ANSWER Name MUST ANSWER MUST ANSWER Group Report # Date of Birth I hereby authorize my physician to release any information acquired in the course of my examination.

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