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Appointment/Procedure Location [radio* Location default:1 "I don't have an appointment scheduled yet" "Ballantyne" "Ballantyne Endoscopy Center" "Endoscopy Center of Lake Norman" "Huntersville" "Matthews" "Mint Hill" "Mooresville" "Mooresville Endoscopy Center" "Randolph Road" "Randolph Road Endoscopy Center"]
I authorize any holder of medical or other information about me to release to insurance carriers, the Social Security Administration and Health Care Financing Administration (or its intermediaries or carrier), and/or any physician Charlotte Gastroenterology & Hepatology refers me to, or any information needed for this or a related insurance and/or medical claim.
I hereby assign to the physicians all payments for hospital/medical/surgical services rendered to myself or my dependents.
I understand that I am responsible for any amount not paid by insurance.
I understand that Charlotte Gastroenterology & Hepatology, PLLC accepts Medicare assignment for Medicare claims and all regulations pertaining to Medicare assignment and benefits apply.
I have read (or had read to me) all of the above and understand all parts of this authorization.
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