HIPAA and Assignment of benefits






(Please click below to draw/upload sign)
(Your IP Address :IP:3.235.78.122 )




(Please click below to draw/upload sign)
(Your IP Address :IP:3.235.78.122 )

HIPAA and Assignment of benefits Preview













Patient Signature
Jun 27,2022
( IP:' 3.235.78.122 ' )
DATE & IP ADDRESS





Patient Signature
Jun 27,2022
( IP:' 3.235.78.122 ' )
DATE & IP ADDRESS