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Pre-Authorization Health Care Form
I authorize Dr. Paul A. Weiss to keep my signature on file and to charge to my
___ Master ___ Visa ___ American Express ___ Discover
Balance of charges not paid by insurance within 60 days until ___________________.
I assign my insurance benefits to Dr. Paul A. Weiss. I understand that this form is valid
unless I cancel authorization through written notice to the health care provider.
| ______________________________________________________________________ | |||
| Patient Name | |||
| ______________________________________________________________________ | |||
| Cardholder Name | |||
| ______________________________________________________________________ | |||
| Cardholder Billing Address | |||
| __________________________________ | ________________ | _______________ | |
| City | State | Zip | |
| ____________________________________________________ | Mo. ____ | Yr. ____ | |
| Account Number | Expiration Date | ||
| X ____________________________________________________________________ | |||
| Cardholder Signature | Date | ||
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