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Patient Information Form

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    Patient Information

    Primary Insurance

    Secondary Insurance

    I understand that payment is due at the time service is rendered. I hereby authorize the release of any medical information to my insurance company through which I claim benefits. I hereby assign all benefits that I am entitled, including Medicare, private insurance, group policy benefits, or other health plans to Rhett Women’s Center. I understand that I am financially responsible to Rhett's Women's Center for all charges not covered, approved or consid-ered necessary by my insurance company. I will pay at the time of service or have an agreeable payment arrangement set up with the business office.