HIPAA and Assignment of benefits






(Please click below to draw/upload sign)
(Your IP Address :IP:3.236.55.22 )




(Please click below to draw/upload sign)
(Your IP Address :IP:3.236.55.22 )

HIPAA and Assignment of benefits Preview













Patient Signature
Sep 27,2021
( IP:' 3.236.55.22 ' )
DATE & IP ADDRESS





Patient Signature
Sep 27,2021
( IP:' 3.236.55.22 ' )
DATE & IP ADDRESS