Eye Care Vision Center of Wauwatosa

  • Patient Information

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  • Vision and Medical Information

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  • Signature

    I understand that, although I may have insurance, I am responsible for non-covered services, co-payments, or any claims submitted to my insurance company that are not paid by my insurance company for any reason. I also understand that if my account becomes delinquent and must be placed with a collection agency, I will be charged any fees incurred in addition to the unpaid balance.
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