HIPAA and Assignment of benefits






(Please click below to draw/upload sign)
(Your IP Address :IP:3.236.221.156 )




(Please click below to draw/upload sign)
(Your IP Address :IP:3.236.221.156 )

HIPAA and Assignment of benefits Preview













Patient Signature
Jun 26,2022
( IP:' 3.236.221.156 ' )
DATE & IP ADDRESS





Patient Signature
Jun 26,2022
( IP:' 3.236.221.156 ' )
DATE & IP ADDRESS