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Web i acknowledge that it will be my resposibility to pay for charges and cost incurred in total. Thank you for choosing us as your health care provider. Web agreement of financial responsibility. Edit your.
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Thank you for choosing us as your health care provider. The financially responsible party as identified on the patient information form and who signs on this form is ultimately responsible for the. Use a patient responsibility letter template template to make your document workflow more streamlined. Thank you for choosing urgent care center of port orange, llc, dba advanced urgent care (auc) as your healthcare.
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