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I hereby authorize payment directly to Atlantic Foot & Ankle Specialists for the surgical and or medical benefits, if any, otherwise payable to me for services. I understand that I am financially responsible for the charges not covered by my insurance.
I authorize Atlantic Foot & Ankle Specialists to release any information, for insurance purposes, required in the course of my treatment.
I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read) and understood the notice.
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