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Medical History
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Eye History
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Note: Most insurance plans either: Do not cover Contact Lens Evaluation or
Require a copay.
Contact Lens Wearers only:
Medical History:
Do you have any of these medical conditions?
Family Medical History
Does anyone in your family have any of these medical
conditions?
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Family Eye History
Does anyone in your family have any of these eye conditions?
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Review Of Systems
Social History
Notice of Privacy, Policies and Agreement
Patient acknowledges that
It is the patient's responsibility to check if we are out-of-network with their
insurance plan prior to
their visit.
It is the patient's responsibility to file insurance claims if we are not contracted
with your
insurance company.
I understand that all charges for professional services rendered are my
responsibility. I
understand this office, if contracted with my insurance company, will file a claim
to my insurance
company on my behalf.
I authorize payment of benefits to Eric Verret OD, Inc.
Your doctor will accept the fee approved by your insurance as payment in full for
any covered
services. The patient will be responsible for any amount approved but not paid by
the insurance
as well as the full amount for all non-covered services.
I agree to assume responsibility for co-payments and deductibles as specified by my
insurance
and for the charges of any non-covered services.
NOTICE OF PRIVACY PRACTICES
Please read our Notice of Privacy
I hereby acknowledge that I received a copy of this medical practice's Notice of
Privacy
Practices and that I will be offered a copy of any amended Notice of Privacy
Practice at each
appointment.
RELEASE OF MEDICAL INFORMATION
I authorize release of my medical information to the following persons.
PHYSICIAN PATIENT ARBITRATION AGREEMENT
please read our Patient Arbitration Agreement