(305)667-6920
 
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Insurance Assignment And Release

I certify that I,and or my dependants, have insurance coverage with

and assign directly to Dr. Ino Halegua, all Insurance benefits, if any, otherwise payable, to me for services rendered. 1 understoond that i am financially responsible for all charges whether or not paid by insurance. i authorize the use of my signature on all insurance submissions. The above named physician may use my health care information and may disclose such information to the above named Insurance Company and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services.This consent will end when my current treatment plan is completed.

Records Release Authorization

To

Doctor Or Hospital,

I hereby authorize and request you to release to:

Dr. INO B HALEGUA

370 MINORCA AVE

SUITE 101

CORAL GABLES, FL 33134

305-667-6920 FAX 305-663-2612

The complete history records in your possession, concerning my illness and/or treatment during the period from

to
Insurance