• PATIENT REGISTRATION FORM

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  • VISION INSURANCE

  • MEDICAL INSURANCE

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  • MEDICAL HISTORY

  • CONTACT LENS HISTORY

  • OCULAR HEALTH EVALUATION

  • We believe checking your eye health is just as important as your vision! The doctor is concerned about retinal problems like Macular Degeneration and Glaucoma, as well as systemic diseases such as Diabetes and High Blood Pressure. These conditions can lead to partial vision loss or blindness, and often can develop without warning and can progress without symptoms. We highly recommend doing the following two options in order to assess your ocular and systemic health. (Opting for both tests is best)

  • NOTICE OF PRIVACY PRACTICES

  • This notice describes how your personal health record information may be used or disclosed and how you may gain access to this information. Examples of uses of your health record information include patient recall, prescription verification or request, and for co-management with another health professional. Signing below indicated that you have been made aware of our privacy practices. We will gladly provide you with a copy of this notice if you would like to keep one for your personal records.

  • AUTHORIZATION OF INFORMATION

  • I hereby authorize Eyes On Norbeck Vision Care to apply for benefits on my behalf for covered services rendered by them. I request payment to be made directly to their office. I understand that I am financially responsible for the charges not covered by my insurance company. I certify that the information I have reported with regards to my insurance coverage is correct and further authorize the release of any information, including medical information, for this or any related claim. I permit a copy of this authorization to be used in place of the original. If in the event my account is turned over to a collection agency, I will be responsible for all collection costs, interest, attorneys’ fees and court costs. Please note: The patient is responsible for full payment of services if information is not made available, not current, information is not accurate, benefits are not available, or patient fails to present insurance information. The patient will also be responsible for submitting themselves to agencies for reimbursement if proper information is not provided to office staff.

    Thank you for choosing us for your eye care needs. We are delighted to have you as a patient and appreciate the confidence you have placed in us. If you have any questions about this form, please do not hesitate to ask.

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