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DEMOGRAPHICS AND RELEASE

DEMOGRAPHICS

DOCTORS

EMPLOYMENT HISTORY

ASSIGNMENT AND RELEASE

I, the undersigned verify that, to the best of my knowledge, the information above is correct. I assign directly to Dupage Health and Wellness all insurance benefits. If any, otherwise payable services are rendered, I understand that I am financially responsible for changes whether or not paid by insurance. By submitting this form you fully understand that Dupage Health and Wellness is not a participant of Medicaid or Medicare and will not provide services to Medicaid or Medicare patients at this time. I hereby authorize release of information necessary to secure the payment of benefits. I authorize the use of this signature in all insurance submissions.

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

I acknowledge that I have been offered or have received a copy of the Privacy Notice.

MESSAGE AUTHORIZATION

Please Select Yes or No for the following questions:

The following allows Dupage Health and Wellness to obtain records from your previous or current health care provider (if you have one).

To provide records to the office personnel at the Illinois offices of:

DuPage Health

The information to be released is confidential. Further disclosure by the receiving party is strictly prohibited except as specifically authorized.

I understand that I may revoke this consent at any time, except if action has already been taken in regards to this request. This consent automatically expires upon compliance of this request and will not serve for any future request.