Auto Accident
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The Following Information is Very Important:
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I HEREBY AUTHORIZE DR. STUART I. SPRINGER TO RELEASE ANY INFORMATION ACQUIRED IN COURSE OF MY EXAMINATION AND TREATMENT TO MY INSURANCE COMPANY
I ALSO AUTHORIZE PAYMENT TO DR. STUART I. SPRINGER FOR THE SURGICAL AND / OR MEDICAL BENEFITS DUE UNDER THE ARMS OF MY INSURANCE POLICY.
I AM AWARE THAT MY INSURANCE COMPANY MAY OR MAY NOT PAY FOR DURABLE GOODS I.E. (SLINGS, ACE BANDAGES, CRUTCHES, ETC.)
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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.