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Eye Associates of Alexandria – Patient Infoadmin2021-01-13T17:47:52+00:00

Eye Associates of Alexandria - Patient Info

Step 1 of 2

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  • Patient Registration

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

  • Patient Financial Information Sheet

  • I understand that payment in full is due at time of service unless other arrangements
    have been made.

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • I understand that I am responsible for any insurance deductible, copay, and
    non-covered services:

  • Authorization and Release:

    I authorize the release of any information including the diagnosis and the records of any
    treatment or examination rendered to my child or me during the period of such care to third
    party payers and/or other health practitioners.

    I authorize and request my insurance company to pay directly to the doctor, insurance benefits
    otherwise payable to me.

  • I authorize the release of any information regarding my care to:

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