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Insurance Information:(In Order to bill your Insurance company .this section must be completed in full)
HOW DID YOU HEAR ABOUT US
Please give us detailed information so we can give proper thanks to those who referred us
RECORD RELEASE & ASSIGNMENT OF BENEFITS
I hereby authorize HALLANDALE MEDICAL CENTER to release pertinent information regarding my care to other physicians involved in my case and / or insurance
companies holding policies on me. I authorize my insurance company to directly remit payment to HALLANDALE MEDICAL CENTER for medical or surgical services
provided and billed.