Nassau Suffolk Neurology
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Neurologist near West Islip
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400 West Main, Street Suite 100, Babylon, NY 11702
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Patient Information
Nassau Suffolk Neurology
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Patient Information
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I GIVE THE PHYSICIAN AND OFFICE STAFF PERMISSION TO DISCUSS MY MEDICAL CONDITION WITH:
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I request that payment by my insurance carrier be made directly to the doctor at Nassau- Suffolk Neurology, P.C. for service(s) described. I accept full responsibility for the unpaid portion of the bill (20% and deductible for Medicare, copay, and/or co-insurance for HMO plans). Nassau- Suffolk Neurology, P.C. reserves the right to collect all unpaid balances. I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing administration or the intermediates or carriers, or to the billing agent of this physician, an information needed for this or a related medical claim. I permit a copy of the authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. I also authorize my medical records at another physician/facility be released to the above practice upon request.
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