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4911 LC Eye Clinic
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2020-12-17T23:14:28+00:00
4911 LC Eye Clinic
Patient Information
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Address Line 2
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Name of Emergency Contact or Legal Guardian
*
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I currently wear
Select All
Glasses
Contacts
Who Prescribed?
Who may we thank for referring you to us?
Insurance Information
We gladly accept the following Insurance plans(please check if applicable)
Regence or BC/BS
Medicare
Medicare Supplement
Group Health
Community Health Plan
First Choice
DSHS
Premera
Tricare
Name of Subscriber
Subscriber I.D. No.
If your insurance is not listed above, we would ask that payment be made when services are rendered. We will provide an insurance bill that you can send in to your insurance company for reimbursement.
*
I accept
I understand that I am responsible for payment of any charges not covered by my insurance. I authorize payment of healthcare benefits to this clinic. I also authorize release of any medical records necessary to process any claims.
Full payment for services, glasses and contacts is due when received. Thank You.
*
Signature of Patient/ Guardian
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