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I authorize the release and disclosure of any or all of my medical and treatment records or reports to any other
health care provider who may be of assistance, in the opinion of Tomeka Roberts, MD, PC, and/or for assisting in any
reimbursement or medical benefits to which patient may be entitiled. I allow fax transmittal of my medical records,
if necessary. I further authorize and request that insurance payments be made directly to Tomeka Roberts, MD, PC should they
elect to receive such payment. This is a direct assignment of my rights and benefits under this policy. A photocopy of this
assignment shall be considered as effective and valid as the original.
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I acknowledge full financial responsibility for services rendered by Tomeka Roberts, MD, PC. I understand that payment of
charges incurred is due at the time of service unless other definite financial arrangements have been made prior to treatment.
I agree to pay all reasonable attorney fees and collection costs in the event of default of payment of my charges.
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I authorize treatment by Tomeka Roberts, MD, PC physicians and personnel.
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I have read and fully understand the above consent for treatment, financial responsibility, release of medical information
and insurance authorization. This authorization is valid for one year.
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