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Powell Vision Centeradmin2017-07-06T01:14:25+00:00

Powell Vision Center

Patient Registration Form
  • MM slash DD slash YYYY
  • Insurance Information

  • 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.

  • (Please Initial)
  • (Please Initial)
  • (Please Initial)
  • Signature (Parent Signature if patient is a minor)
  • MM slash DD slash YYYY
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