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I confirm I am the patient (or the patient or guardian if the patient is under 16 years of age) and wish to claim benefits and declare that all the particulars given above are to the best of my knowledge true and correct. In respect of my medical claim, I hereby consent to and authorize the medical practitioner, health professional or other relevant medical establishments to provide to discuss and health/treatment details, medical records or discharge arrangements(past and present) with and to the Insurer and/or Third Party Administrator. I agree that a copy of this consent shall have the validity of original.
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