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Confidential Patient Information
* = Required Information
910 N Hwy. 146, Suite A
Baytown, TX 77520
Phone: 281-837-7571
Fax: 281-664-3789
Male Female
Single Married Widowed Divorced Separated

I hereby authorize the release of any medical information necessary for processing insurance claims and payment of medical benefits for myself or the party who accepts assignment of benefits.