Medical Arts Press® Financial Agreement and Insurance Assignment; 4x5-1/2" Bond Non-Personalized
$5.69
5+ pad
Medical Arts Press® Financial Agreement and Insurance Assignment; 4x5-1/2" Bond Non-Personalized
Item #:
901-33404
Model #:
33404
Brand:
Medical Arts Press
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$5.69
5+ pad
Order in multiples of 5
Medical Arts Press® Financial Agreement and Insurance Assignment; 4x5-1/2" Bond Non-Personalized
Frequently bought together
Price Drop
Item #: 901-33404
$5.69
5+ pad
$28.45
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Total
$234.43
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Description
Form certifies that patients are responsible for all fees, regardless of any insurance reimbursement. By completing and signing this form, patient agrees to pay all fees at the time of service. Printed in black on white 20 lb. bond.
- 100 sheets per pad
- Pad size: 4 x 5-1/2 inches
Specifications
Brand
Medical Arts Press
Environmental Design Features
Yes
Form Size
4" x 5 1/2"
