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Patient Medical Forms:

All Patients Must Fill Out the Following Medical Forms:

Contact Lens and Vision Patient Record Form

QuanitifEye and Retinal Photography Form

Dry Eye Symptoms Questionnaire

HIPAA Privacy Acknowledgement of Notice of Privacy Practices Form

Contact Lens and Vision Notice of Privacy Practices (for your own records)

Patients With Insurance Must Fill Out the Following Forms:

Advance Beneficiary Notice (ABN)

Patient Medical History Form

Patient Medical Release, Lifetime Signature on File, and Credit Card Form

Patients With Medicare Must Fill Out the Following Forms:

If you have Medicare you do not need to fill out the insurance forms above.

Advance Beneficiary Notice of Non-Coverage Form

Patient Insurance Information Form

Patient Medical History Form

Patient Medical Release, Lifetime Signature on File, and Credit Card Form

 

 

 

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