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Medicare ABN Form
Sara Mikulsky Wellness Physical Therapy, PLLC
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By checking "I Agree" you agree to the terms listed in this link
https://drive.google.com/file/d/12aJ1otEyN9_vAkSwU2kOAuI8Br7triOq/view?usp=sharing
and understand that this is a non-covered service under Medicare guidelines. You agree to be responsible for payment. By clicking "I Agree" this serves as your signature.
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