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  • Responsible Party for Minors

  • Insurance Information

  • Secondary Insurance if Applicable

  • Assignment of Benefits and Financial Agreement

    I hereby consent to treatment by the physicians and/or associates of Frisco Obstetrics and Gynecology , P.A.
  • Authorization

    I hereby authorize payment of insurance benefits to be made to Frisco Obstetrics and Gynecology, PA and any assisting physicians, for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collections and reasonable attorney fess. I also authorize Frisco Obstetrics and gynecology, PA to release any and all information necessary to secure payment of benefits. I further agree that a photocopy of this agreement or electronic signature is as valid as an original.
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