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Powell Vision Center
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2017-07-06T01:14:25+00:00
Powell Vision Center
Patient Registration Form
Date
MM slash DD slash YYYY
Patient Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
SS# (Required for Insurance Purposes)
Gender
Male
Female
Communication Preference
Telephone
Text
Email
Martial Status
Single
Married
Widowed
What is your spouse's name?
Place of Employment
Occupation
Email
Reason for choosing Powell Vision Center
Insurance Information
Vision Insurance Company
Member Name
Member SS# (Required for Insurance Purposes)
Member D.O.B.
MM slash DD slash YYYY
If we cannot pre-authorize your insurance benefits, you are expected to pay in full at time of service. If you request that we resubmit a claim at a later time (no later than 60 days from the date of service), there will be a $35.00 fee. Powell Vision Center is authorized to release all information necessary to secure payment of services.
I understand that my insurance does not pay for everything, even some care that I or my health care provider have good reason to think I need. Test including, but not limited to, visual field, medical optomap and OCT will be billed to insurance. If my insurance denies payment of these tests or services, I am responsible for payment in full and I have the right to appeal to my insurance company.
(Please Initial)
I understand that eyewear purchases are custom orders and therefore, all sales are final. Lenses will be replaced free of charge for up to 60 days if my prescription requires adjustment.
(Please Initial)
HIPAA Notice: We are required by applicable federal and state law to maintain the privacy of your health information and to inform you about our privacy practices. This notice was effective April 14, 2003 and will remain in effect until we replace it. All information regarding how your information may be used is included in our privacy notice, and you may request a copy of it at any time. By signing this form, you acknowledge that our privacy practices have been made available to you and that you agree to them.
(Please Initial)
I hereby certify that all information provided is complete to the best of my knowledge and I agree to all terms stated herein
Signature (Parent Signature if patient is a minor)
Date
MM slash DD slash YYYY
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