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Medicare/Insurance Form
Fields marked with * are required.
Assignment of Benefits ~ By Checking the Yes Box, I request the payment of authorized Medicare and/or insurance benefits be made on my behalf to Women's Health Boutique for any services furnished to me. I understand that Women's Health Boutique assumes unconditional responsibility for refunding any overpayments that are made by Medicare or my insurance Carrier. 
Release of Medical Information / Medical Records ~ By checking the Yes box I hereby authorize any holder of medical information concerning me to be released to Women's Health Boutique.. I also authorize copies of my medical records be mailed or faxed to Women's Health Boutique, upon request, in order for medical claims to be filed on my behalf to Medicare and /or insurance.