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The above information on all pages of this document is thorough and accurate to the best of my knowledge. For any changes to the above information, I will notify the office.
I consent to evaluation, payment/insurance policy, and treatment by any provider at Synaptic Pediatric Therapies. I hereby authorize release of medical information that is necessary for my further treatment.
I authorize release of information, including treatment and protected health information to my insurance company that is needed to process payment for services. I authorize my insurance carrier to pay benefits for services rendered, directly to Synaptic Pediatric Therapies LLC, or any of its affiliates. I have read and agree to the terms of the above information.
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