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AnxietyArthritisArterial FibrillationBreast CancerColon CancerCOPDCoronary Artery DiseaseDepressionDiabetesRenal DiseaseGerd (Influx)Hearing LossHepatitisHigh Blood PressureHIV / AIDSHigh CholesterolLeukemiaLung CancerLymphomaProstate CancerRadiation TreatmentSeizuresStrokeHypothryroidHyperpthyroidCancerNone Apply
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I AUTHORIZE THE RELEASE OF MEDICAL INFORMATION TO MY PRIMARY CARE OR REFERRING PHYSICIAN, TO CONSULTANTS IF NEEDED AND AS NECESSARY TO PROCESS INSURANCE CLAIMS, INSURANCE APPLICATIONS, AND PRESCRIPTIONS. I ALSO AUTHORIZE PAYMENTS OF MEDICAL BENEFITS TO PALMS ACUPUNCTURE AND WELLNESS.
PAYMENT IS REQUIRED FOR ALL SERVICES AT THE TIME THEY ARE RENDERED. I HAVE HAD A CHANCE TO READ OVER THE FINANCIAL RESPONSIBILITY FORM.
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2151 S Alternate A1A Suite 1400 Jupiter, FL 33477
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