By submiting the Registration Form you agree to the following:

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly

to the physician.

I understand that I am financially responsible for any balance. I also authorize Z Medical Care or insurance company to release any information required to process my claims.

I have received and read the HIPPA Privacy Notice and I am aware of my rights as a patient. I make the following special request for confidential communication.


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