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Release of Information
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Date of Birth
May Dr. Grant or his associates send you a letter to your home address?
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If you want insurance claims filed, please complete below:
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Insured's Birth Date
I authorize the release of treatment data, including drug and alcohol information, if required by my insurance. I also authorize all behavioral health benefits payable under my insurance policy to Matthew G. Grant, Psy.D., HSPP-NorthStar Psychological + Consultation Services, LLC so that they may be applied to my account. The remainder left unpaid is my responsibility unless otherwise stated.
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Date (Today's Date NOT your DOB)
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