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Get Sample Ambulance Signature/Claim Submission Authorization Form 2014-2024
Y Practices Acknowledgment: by signing below, the signer acknowledges that ABC Ambulance Service (ABC) 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 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 secti.
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