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F'O ~OX 223 <br /> <br />EL.K I::tI VF-~ MN 55330 04/1B/lEI 65Y 2 OP <br /> <br /> 441-4196 474,'~a-.-1.~- 2 B,49 LDS - <br />'-~~ ..... ~.~~-~;~-~.: ~T~:~*-~ ~ ~ -- <br /> ~UCHITE ~RICH~RD H 03/04/83 <br /> <br /> ~ ~H~L~ <br />CZTY-OF R~HBEY EGUZP DP *-' <br />NOgTHEN BLUD ' <br />~NOK~ ~N ' <br /> <br />Po ~ox 223 ~ Po ~ox..223 <br />ELK RZUER HN. S~330 ' ~ ELK RZUER , NH 5~330 . <br /> <br /> RhMSEY EOUZP OP <br />CITY <br /> OF <br />HOWTHEN ~LUD <br /> <br /> CT.L SPINE~R/O HIUD ~ 04 <br />  <br /> CT,L ~PINE <br /> <br />WORK COMP CITY OF R~MSEY <br /> <br />~ M~I~E A~HOR~H * <br /> <br /> 3. AUTHORIZATION TO RELEASE DIAGNOSIS/ASSIGNMENT OF BENEFITS <br /> I~e hereby aulhorize Unity Medical ~nter tO release diagnostic information necessa~ to determine our insurance benefits and to allow <br /> our Insurance company to determine the validity of the claim. The claim may be sent through my employer or Union, if appropriate. II <br /> luther inform~tlon Is needed from the medi~l record, a separate author~ation is necessa~. <br /> I hereby assign my basic and major m~l~l insurance ~nefits to Unity Medical ~nter and dir~! payment to be mailed to them, but not tc <br /> exceed the charges Itemized on the statement to be enclosed with this form. I understand the assignment of these ~nefi~s in no w~ affects <br /> my obligation to pay Unity Medical ~nter for this h~pi~l treatment. A Photocopy of this Authorization and Assignment shall be <br /> considered as valid as the original. <br /> <br /> 4. GU~EOFAC~U~ ' ' ' **: * <br />  H~ <br /> <br /> <br />