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HALLANDALE

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Patient Information

M F
S M D W
FIRST NAMELAST NAME


Insurance Information:(In Order to bill your Insurance company .this section must be completed in full)

last for digits of your SSN only
M F
last for digits of your SSN only
M F


HOW DID YOU HEAR ABOUT US

Insurance Directory
Internet
Other


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.

Print Patient Name
Signature
Date

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