able aeon your demand. Rat total rs waddin the carat prodclomp value. Le4ireg infoweremieet fa detailed Scallion on the f nWs lerdro practices ad Outman ran to tar Clare Ralattornhp Agenrent a adlOat dultrilted ad the Genteel Time and Cadrtiors LOS kelernent of Credit audios avaktle n Arena: and CX

yes. Insurance Company: ---=resst Grotm*: a3aceos Insureds DOB: TAM a Or 19 53 Ration to patient c cirt 0 No Insureds ID re Hue your inauroncs Outman, slow your CM VISIT? C vet O No (if yes. Pease fill out insurance information above and supply your new insurance card(s) to the front desk recepa

plete and redound* to the ben knowledge of the undingnad and (i) the undersigned M responsible for the method of transmission of any maw:dons issued Outman to this authorization. If the undefagnth etecto to twowne any such instructions via fax (inducing Steep fag. via email or es en image attachment to

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ocedse. Free Credit Balances (Rule 1603.2 & 3): Under me dent protection aft. wo may use free dada balances in your Meant n IN Ordinary Cane al our Outman which we parable to yOu on award. Margin Accounts (Regulation T): H you have a margin account. this report e a combnahan of your margin aftent and