Release of Information and Authorization to Pay Insurance Benefits Sample Contracts

CONDITIONAL AGREEMENT
Release of Information and Authorization to Pay Insurance Benefits • April 7th, 2022

RELEASE OF INFORMATION: THE UNDERSIGNED AUTHORIZE THE OFFICE OF HIGHLAND FAMILY PRACTICE TO RELEASE PART OR ALL OF THE PATIENT’S RECORDS TO ANY PERSON OR ORGANIZATION LIABLE FOR THE BILL (CHARGES). THE UNDERSIGNED AUTHORIZE THE OFFICE OF HIGHLAND FAMILY PRACTICE TO SEND ELECTRONIC CONFIRMATIONS.

Sample 1
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