HIPAA and Assignment of benefits






(Please click below to draw/upload sign)
(Your IP Address :IP:44.200.112.172 )




(Please click below to draw/upload sign)
(Your IP Address :IP:44.200.112.172 )

HIPAA and Assignment of benefits Preview













Patient Signature
May 28,2023
( IP:' 44.200.112.172 ' )
DATE & IP ADDRESS





Patient Signature
May 28,2023
( IP:' 44.200.112.172 ' )
DATE & IP ADDRESS