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Get SC Advanced Pain Specialists Consent For Treatment And Release Of Information And Payment 2014-2024

Treatment and Release of Information and Payment Authorization Medicare Patients Only I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I authorize and request that payments of authorized Medicare benefits be made directly to Advanced Pain Specialists of Southern California, or its representative, for all services rendered.

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