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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