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Tion section If paying with MasterCard or Visa, you must present your credit card the day of the clinic. If paying with Medicare Part B, Medicare Railroad, Medicaid, Aetna, Aetna Medicare, Caresource, United Health Care, Cigna, or The Health Plan, you must present your medical card the day of the clinic. Answer the questions in the Authorization section Print the form (form cannot be saved) Sign and Date Bring completed form and credit card and/or medical card (if applicable) 1) DE.

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