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Ce Svc, Inc. (SAS) provided a copy of its Notice of Privacy Practices to the patient or other party with instructions to provide the Notice to the patient. * A copy of this form is as valid as an original* SECTION I - PATIENT SIGNATURE The patient must sign here unless the patient is physically or mentally incapable of signing. NOTE: if the patient is a minor, the parent or legal guardian should sign in this section. I authorize the submission of a claim for payment to Medicare, Medicaid, or a.
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