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Lung Cancer Screening Form - Patients

General Information

5 digit zip code
Include area code

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.

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.