Patient Registration Form Page 5

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Please inform us of all Insurance Plans you are covered under even if
you have Apple Health, Provider One, or DSHS.
Billing Insurance Plans out of order can result in claims being denied or
payments being recouped by an Insurance Carrier, and can result in
additional patient financial responsibility.
I have informed you of all of the Insurance Plans I am covered under.
Signature:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_

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