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Blaine Family Eye Care LtdBerenice2023-02-03T00:55:19+00:00

Blaine Family Eye Care Ltd

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  • Patient Registration

  • MM slash DD slash YYYY
  • XXX-XX-XXXX
  • Employment Information

  • Vision Insurance Information

  • MM slash DD slash YYYY
  • Drop files here or
    Max. file size: 512 MB.
    • Medical Insurance Information

    • MM slash DD slash YYYY
    • I authorize Blaine Family Eye Care to release or exchange any information necessary to process my insurance claims. I request that payment of authorized benefits, including Medicare, be made to this clinic for services furnished to me by any provider employed by this clinic. I understand that I am financially responsible for any balance not covered by my insurance carrier, and that a quotation of benefits is not a guarantee of coverage.
    • Medical Information

    • MM slash DD slash YYYY
    • Current Medical Problems

    • Medical History

    • All Current Medications

    • At Blaine Family Eye Care we keep a record of the health care services we provide to you. You may request a copy of your medical record in writing or get more information by contacting our privacy officer. We will not disclose your record to others unless you direct us to do so or unless legal authorities authorize or compel us to do so. Our Notice of Privacy Practices is available at the reception desk. The Notice describes in greater detail how your health information may be used or disclosed, and how you can access your information. You are entitled to a copy of this Notice and it is available at your request.

    • I acknowledge the Notice of Privacy Practices has been offered to me and is readily available in accordance with the Health Insurance Portability and Accountability Act.
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