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  • REGISTRATION FORM

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  • PATIENT INFORMATION

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  • INSURANCE INFORMATION

    (Please give your insurance card to the receptionist
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  • IN CASE OF EMERGENCY

  • The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Radiology Associates or insurance company to release any information required to process my claims.

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