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Eye Health Solutionsadmin2019-02-04T14:32:53+00:00

Eye Health Solutions

Patient Registration
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  • Signature of Patient or Parent/Guardian

    I am responsible for payment at the time of each visit for all services provided by Dr. Scott Smith or Eye Health Solutions which are not covered by insurance. I authorize assignment of all medical benefits to Dr. Scott Smith or Eye Health Solutions, and I authorize the release of any medical information needed to process insurance claims. This acknowledgement and authorization applies to all services until revoked by me in writing.
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