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Get Wa Advanced Spinal Care Doctors Lien 2017-2024

Atient s Name: I hereby authorize the above doctor to furnish you, my attorney/insurance company, with a full report of the case history, examination, diagnosis, treatment, and prognosis of myself in regard to the accident in which I was involved. I hereby authorize and direct you, my attorney/insurance company to pay directly to said doctor/clinic such sums due and owing his/her for professional services rendered to me both by reason of the aforesaid accident and by reason of any other bills.

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