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Wilmette Eye Careadmin2018-07-23T22:13:36+00:00

Wilmette Eye Care

Wilmette Eye Care Patient Registration Form

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  • Insurance Information

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  • Patient History

  • Contact Lenses

  • I authorize Wilmette Eye Care to bill my insurance when possible. I understand that the amounts quoted are not a guarantee of benefits and that I may be financially responsible for charges not covered by my insurance. I authorize the use of my signature on all insurance submissions. I acknowledge that I was offered an opportunity to review or requested and received a copy of our Notice of Privacy Practice for HIPAA.
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