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Eye Center of Connersville
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2017-07-06T01:14:21+00:00
Eye Center of Connersville
Patient Information
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SSN
*
Referral
Home Phone
*
Family Physician
Contact Info
Contact Home Phone
Contact Cell Phone
If the patient is a minor, the following must be complete:
Responsible Party
Address (if different from patient's)
Patient Relationship to Responsible Party
Insurance ID #
Date of Birth for Responsible Party
MM slash DD slash YYYY
All patients and/or responsible parties, please complete the following:
Employer
*
Email
*
Primary Insurance
*
Subscriber's Date of Birth
*
MM slash DD slash YYYY
Subscriber's ID #
*
Relationship to Patient
*
Date
*
I hereby authorize my Insurance carrier(s) to submit payment for services provided to me directly to Whitewater Eye Centers and/or Whitewater Surgery Center. I authorize any holder of medical information about me to release to my insurance carriers any information needed to determine benefits payable for related services. I request payment of authorized Medigap benefits as applicable to be released to Whitewater Eye Centers and/or Whitewater Surgery Centers. I understand that I am responsible for payment of services and failure to pay amounts owed by me may be subject to collection fees of up to 50% of the delinquent amount and/or attorney and court fees as applicable.
I hereby acknowledge receipt of the Whitewater Eye and Surgery Center Patient Privacy notice issued on the date below.
MM slash DD slash YYYY
Signature
*
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