Baird Optical Co Inc Patient Registration Form

Step 1 of 2

  • Patient Registration Form

  • Guarantor: If patient is a minor

  • Insurance Information

  • Medicare Signature on File: I request that payment of authorized Medicare payments be made on my behalf to Baird Optical Co, Inc. for services furnished to me. Furthermore, I have authorized to release to my insurance carrier(s) any and all information needed to determine the benefits payable to related services. Although the providers of Baird Optical Co, Inc. may or may not participate with my insurance carrier(s), I understand that I am financially responsible for co-payments, deductibles and unpaid balances.
  • Date Format: MM slash DD slash YYYY
  • Contact Method

  • Date Format: MM slash DD slash YYYY