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Get Medical Release Form For Insurance Billing Patient Information ...

Group/Plan Name: Insurance Address: Policy # Name of Insured: Address: Date of Accident / Injury: Brief description of accident / injury: By signing below I agree that all of the information I have provided is true and I give permission to L.M.T at InMotion 24-7 to release medical records to my insurance company for the purpose of receiving payment. Under the circumstance that my insurance company does not pay for my scheduled office visits I will be responsible for.

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