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Get Eaglemed Ambulance Billing Authorization Form 2013-2025

Patient or as the legal representative, or surrogate for consent to treatment, on behalf of the patient named above): (1) acknowledges that the medical care furnished to the patient was actually received and was limited solely to emergency treatment and transporation; (2) authorizes such medical treatment and transportation as being medically necessary; (3) authorizes and directs any holder of medical information or documentation about the patient to release such information to Supplier, its bil.

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