· 6120 east state road 70, bradenton, fl. 34203 office: 941-752-1916 assignment of insurance...

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Page 1: · 6120 East State Road 70, Bradenton, FL. 34203 Office: 941-752-1916 ASSIGNMENT OF INSURANCE BENEFITS RELEASE & DEMAND Insurer and Patient Please Read the Following in its Entirety

Page 2: · 6120 East State Road 70, Bradenton, FL. 34203 Office: 941-752-1916 ASSIGNMENT OF INSURANCE BENEFITS RELEASE & DEMAND Insurer and Patient Please Read the Following in its Entirety

Page 3: · 6120 East State Road 70, Bradenton, FL. 34203 Office: 941-752-1916 ASSIGNMENT OF INSURANCE BENEFITS RELEASE & DEMAND Insurer and Patient Please Read the Following in its Entirety

Page 4: · 6120 East State Road 70, Bradenton, FL. 34203 Office: 941-752-1916 ASSIGNMENT OF INSURANCE BENEFITS RELEASE & DEMAND Insurer and Patient Please Read the Following in its Entirety

Page 5: · 6120 East State Road 70, Bradenton, FL. 34203 Office: 941-752-1916 ASSIGNMENT OF INSURANCE BENEFITS RELEASE & DEMAND Insurer and Patient Please Read the Following in its Entirety

Page 6: · 6120 East State Road 70, Bradenton, FL. 34203 Office: 941-752-1916 ASSIGNMENT OF INSURANCE BENEFITS RELEASE & DEMAND Insurer and Patient Please Read the Following in its Entirety

Page 7: · 6120 East State Road 70, Bradenton, FL. 34203 Office: 941-752-1916 ASSIGNMENT OF INSURANCE BENEFITS RELEASE & DEMAND Insurer and Patient Please Read the Following in its Entirety

Page 8: · 6120 East State Road 70, Bradenton, FL. 34203 Office: 941-752-1916 ASSIGNMENT OF INSURANCE BENEFITS RELEASE & DEMAND Insurer and Patient Please Read the Following in its Entirety

Page 9: · 6120 East State Road 70, Bradenton, FL. 34203 Office: 941-752-1916 ASSIGNMENT OF INSURANCE BENEFITS RELEASE & DEMAND Insurer and Patient Please Read the Following in its Entirety

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