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I authorize the release of medical or other information about me to the above listed insurance provider(s). I permit a copy of this 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.

Copays, co insurance, and/or deductibles are due at time of service unless other arrangements have been made. All accounts should be paid within 90 days of insurance being posted to prevent further action. I agree to pay any collection or attorney fees owed in addition to court costs if charges are not paid within the agreed upon terms and legal action is necessary to effect collection.

I certify that I have read all of the above and the information given is true.



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Our Location

Erlanger Medical Mall
979 East Third Street
Suite C-0630
Chattanooga, TN 37403
423.267.5677

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More Info

If you need additional information, please call us at (423) 267-5677, or send an e-mail to info@goodman-gi.com.

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