Statement of Confidentiality I authorize the release of necessary medical information to ZYGO Industries, Inc. for the purposes of processing this or any related insurance claims. I also give ZYGO Industries, Inc. the authority to make available any requested documents contained in my file to myself and/or other health care providers involved in the treatment of my condition. Agreement I acknowledge that I am fully responsible for the payment of any equipment provided to me by ZYGO Industries, Inc. I understand that if ZYGO Industries, Inc. submits a claim for billed charges to my health plan(s) on my behalf, I am not relieved of my financial responsibility for payment. In the event that the health plan or any third party payor does not pay the entire billed amount, I agree to pay any remaining balance except as restricted by specific Medicare and Medicaid reimbursement policies.
By my signature below, I acknowledge and accept the terms and conditions stated above.
Client Name
Client signature (or legal representative)
OPTIONAL: By providing my credit card information below, I understand that my credit card may be billed for any unpaid balances on my account.
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