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The Salem Eyecare Center, Inc
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2017-07-06T01:14:30+00:00
The Salem Eyecare Center, Inc
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Burundi
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Cameroon
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Cayman Islands
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Chad
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Christmas Island
Cocos Islands
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Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
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Mali
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Mayotte
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Nicaragua
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Niue
Norfolk Island
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Palau
Palestine, State of
Panama
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Paraguay
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Philippines
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Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
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Do you have anyone else in your family interested in becoming a patient?
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Name
First
Last
Relation
Date of birth
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Date of last eye exam
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How Did You Find Out About Our Office
*
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Location
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Other
Co-Payments and fees not covered by your insurance are due upon date of service. A DOWN PAYMENT of 50% is required on materials to start your order. The balance will be due upon pick up of your eyewear. THERE ARE NO CASH REFUNDS ON MATERIALS.
If a prior authorization is required by your insurance, it is the patient's responsibility to contact their primary care provider.
FINANCIAL RESPONSIBILITY & ASSIGNMENT OF BENEFITS TO SALEM EYECARE CENTER:
I assign to Salem Eyecare Center all medical and vision benefits to which I am entitled. I understand that I am responsible for all charges for professional services rendered. (Except for participating provider agreements between this corporation and your insurance company). I am specifically responsible for certain co-payments and deductibles. I understand that refractive services and other forms of medical care may not be reimbursed by my health care plan and that I will be responsible for these services. A copy of this agreement is also valid. The agreement shall remain in effect until revoked by me in writing. I understand I will be subject to a re-filing fee for supplying false insurance information at date of service.
FULL AUTHORIZATION FOR INFORMATION TRANSFER:
I authorize this office to furnish information (including sensitive medical information) to insurance carriers, healthcare administrators, healthcare providers, and other agencies concerning my medical condition, personal data, and insurance/billing information.
Signature
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Date
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MM slash DD slash YYYY
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