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Patient Authorization

Also for our records we ask that you review and agree to the following terms:

Authorized Representative

I, , authorize and designate Exclusive Surgeries Solutions LLC as an authorized representative to act on my behalf with respect to all matters related to my rights, benefits, privileges, claims, causes of action, interest, or recovery arising out of any policy of insurance, plan, fund, or coverage, providing health care coverage of any type to me (or to any third party responsible for me). This includes but is not limited to, filing claims and appeals if necessary, receiving all information, documentation, summary plan descriptions, bargaining agreements, contracts and other instruments under which the plan is established or operated, as well as receiving any policies, procedures, rules, guidelines, protocols or other notifications related to claims or appeals.