ASSIGNMENT OF INSURANCE BENEFITS. I hereby request and authorize that any and all insurance benefits due and payable for medical and psychiatric services and rendered to me are to be paid directly to Gladstone Psychiatry & Wellness, LLC.
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Samples: www.gladstonepsych.com, www.gladstonepsych.com
ASSIGNMENT OF INSURANCE BENEFITS. I hereby request and authorize that any and all insurance benefits due and payable for medical and psychiatric services and rendered to me are to be paid directly to Gladstone Psychiatry & Wellness, LLC. Please review the document Consent to Bill and Release Medical Information to Insurance Company on page 7 of this document for further details.
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Samples: www.gladstonepsych.com, www.gladstonepsych.com
ASSIGNMENT OF INSURANCE BENEFITS. I hereby request and authorize that any and all insurance benefits due and payable for medical and psychiatric services and rendered to me are to be paid directly to Gladstone Psychiatry & Wellness, LLC. Please review the document Consent to Xxxx and Release Medical Information to Insurance Company on page 7 of this document for further details.
Appears in 2 contracts
Samples: www.gladstonepsych.com, www.gladstonepsych.com