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Payment Authorization

"*" indicates required fields

Name*
Assignment of Insurance Benefits*
I authorize that the payment of my insurance benefits be made directly to The Center for Balance for any services that are reimbursable by Medicare, Medicaid or any third party payors.
Guarantee of Payment*
I understand that all payments designated as “the patients responsibility” are due and payable at the time of service or billing. I guarantee that I will pay:
Medicare and Workers Compensation Information*
I certify that the information I have provided to The Center for Balance for Initials payment under the Social Security Act (Medicare) or under the Workers Compensation Program is correct, including but not limited to any related accidents/illness or other insurers/payors available.
I understand the statements I have authorized above and Printed Name declare their truthfulness
Patient or Authorized Representative for Patient Signature
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