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PATIENT REGISTRATION
FORM 001
I certify that the above information is a true and complete statement of my financial and insurance situation to the best of my knowledge. I understand that the information I have given is subject to verification by Positive Assistance, Inc. and every effort will be made to keep my information private and confidential. I also understand that I may request a review of the charge(s) if I feel it is inaccurate. For family planning and communicable disease services, I understand that I will not be denied service(s) because of inability to pay.
