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N the patient’s behalf ; (3) a relative or other person who arranges for the patient’s treatment or exercises other responsibility for his or her affairs; and/or (4) a representative of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance services) but furnished other care, services, or assistance to the pt My signature is not an acceptance of financial responsibility for the services rendered. X ______ ________ _______ ____________________.

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