HIPAA and Assignment of benefits






(Please click below to draw/upload sign)
(Your IP Address :IP:18.97.9.173 )




(Please click below to draw/upload sign)
(Your IP Address :IP:18.97.9.173 )

HIPAA and Assignment of benefits Preview













Patient Signature
Feb 11,2025
( IP:' 18.97.9.173 ' )
DATE & IP ADDRESS





Patient Signature
Feb 11,2025
( IP:' 18.97.9.173 ' )
DATE & IP ADDRESS