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ACCOUNT #: DATE: PATIENT'SFIRST NAME LAST NAME MI

ACCOUNT #: DATE: PATIENT'SFIRST NAME LAST NAME MI 2025

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The document is a comprehensive patient information and insurance authorization form for Lehman Advanced Dermatology, PLC. It includes sections for personal details, medical history, insurance information, financial responsibilities, office policies regarding cancellations and late arrivals, privacy practices under HIPAA, and consent for medical photography. The document aims to inform patients about their rights, responsibilities, and the billing process associated with dermatology visits.

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