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Demo Adult

Demographics Update (Adult)

Please fill in the following information. If you do not know something off hand type N/A.


Insurance Information

This is a direct assignment of my rights and benefits under this policy, I agree to pay and charge not paid by insurance. A photocopy of this agreement shall be considered as effective and vail as the original. I authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in the case. I have received a copy of HIPPA ( Health Insurance Portability and Privacy Act) and agree to this policy.

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