1 Patient Demographics


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Mailing Address
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If the patient is under the age of eighteen (18) years of age, the parent or legal guardian must fill out this section.

I hereby give authorization to SRHS Clinic Providers and staff to treat my minor child or myself.  I hereby give authorization for payment of insurance benefits to be made to SRHS Clinics for services rendered.  I understand that I am financially responsible for all charges whether or not they are covered by insurance.  In case of default, I agree to pay all costs of collection and reasonable attorney’s fees.  I hereby authorize this healthcare facility to release any and all information necessary to secure payment of benefits and that a photocopy of this agreement shall be as valid as the original.


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