Lung Cancer Screening - Patient Form

Please let us know your name.
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Please let us know your email address.
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Authorization to Release Information

I hereby release the undersigned to release information acquired in the course of my examination or treatment to insurance companies or authorized physicians.

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Authorization to Pay

I hereby authorize payment directly to the North Alabama Oncology and/or Oncology Specialties, of the medical and/or emergency medical benefits, including major medical insurance, if any, otherwise payable to me for this service as described below. I understand that I am financially responsible for the charges not covered by this authorization.

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YOUR RESOURCES

Cancer Treatment

UNDERSTAND TREATMENT OPTIONS

YOUR RESOURCES

Clinical Trials

REVOLUTIONIZING CANCER CARE

YOUR RESOURCES

Lung Screening

WHY SCREENING SAVES LIVES