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Insurance payment consent

I, hereby certify and attest that I have sought evaluation, treatment, and or medical advice from the staff at the OmeCare Lab (Ome Ventures Inc).

I, therefore, authorize the medical staff and personnel to release my or my minor child’s medical information to my insurance company listed above for the purpose of determining and receiving benefits by medical billing on your behalf. I understand and acknowledge that the medical staff will submit my claim to my insurance company on my behalf.

I further understand that I will be held responsible for any amount of my medical bills not covered by my insurance policy or claims and that I will be responsible for paying all deductibles, fees, co-payments, and co-insurance payments required.

I understand that any portion of my medical bills not covered by insurance will be billed to me at the address I have provided above.

I understand that any payments related to the service I or my minor child have received from my insurance are to be sent directly to OmeCare Lab (Ome Ventures Inc).

 

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