Patient Intake Form: Patient Registration

  • Date Format: MM slash DD slash YYYY
  • I hereby assign, transfer and convey all medical benefits to be paid directly to PASWFL - Dr. Robert W. Pollack and recognize it is my responsibility to pay for all non-covered services. I also authorize PASWFL to release any information necessary to process an insurance claim. In the event the patient is a minor, a parent or guardian who will be responsible for the payment of the bill must accompany the patient. A photocopy of this Assignment will be considered as valid as the original.
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