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Statement of Responsibility |
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In consideration of the services rendered by
the doctors,
Charter
Internal Medicine,
LLC., the undersigned acknowledges that he/she is responsible for all payment for all services and agrees to pay any and all balances due not covered by his/her insurance. |
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| Responsible Party Signature |
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| Print Name |
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________________________________________________ |
| Date |
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| Witness |
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Charter
Internal
Medicine,
LLC |
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10700 Charter Drive,
Suite 200
Columbia, MD 21044-3687
Phone: 410-910-2300 /
Fax: 410-910-2310 |
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