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4906 LC Eye Clinicadmin2020-12-17T23:17:18+00:00

4906 LC Eye Clinic

  • (nickname, Mr./Mrs., Dr., etc)
  • MM slash DD slash YYYY
  • CellHomeWork 
    (###)###-####
  • There are fees to evaluate and update a contact lens prescription. I understand that these fees are not covered
    by most insurance, vision, or managed care plans as it is not considered part of a routine eye exam. I will notify
    the staff if I decide not to have this service performed.
    I understand and agree that health insurance policies are an arrangement between an insurance carrier and
    myself. I authorize payment from my insurance carrier direct to this office with the understanding that all
    monies will be credited to my account of receipt. However, I clearly understand and agree that all services
    rendered are charged directly to me and that I am personally responsible for payment. I also authorize release
    of any medical information that may be required in determination of benefits. I have received a copy of Vision
    Source's Privacy Statement.
  • (If Applicable)
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