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Submit Your Eye Exam Registration

PATIENT INFORMATION

 
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FRIEND/RELATIVE OR EMERGENCY CONTACT

 

PRIMARY INSURANCE

SECONDARY INSURANCE

Our office is fully committed to compliance with HIPAA guidelines by:

1. Providing appropriate security for our patient records.
2. Protecting the privacy of our patient’s medical records.
3. Providing our patients with proper access to their medical records, once a signed release is obtained.
4. Appropriately maintaining our patient information and billing process in compliance with national HIPAA standards.
5. Not providing patient data to marketers or pharmaceutical companies for purpose of research.
6. If Family Member(s) Call or Come In for Information Regarding Your Condition, to Whom May We Release This Information? Please Include Their Name(s) and Relationship(s).
 
 
 
FINANCIAL INFORMATION
I understand that I, as the patient, am fully responsible for payment on my account with Nevada Eye Consultants, regardless of any insurance coverage. All professional services rendered are charged to the patient. Necessary forms will be completed to help Nevada Eye Consultants of any billing or insurance changes. I agree to pay all attorney fees and/or collection fees, should collection become necessary.

RELEASE OF INFORMATION
I authorize the release of any information regarding the course of my examination and treatment to the insurance companies listed, and/or any physicians I may see. I further authorize Nevada Eye Consultants to obtain medical information from any source deemed necessary for my treatment. A copy of this authorization shall be considered as effective and valid as the original.

ASSIGNMENT OF BENEFITS
I authorize and assign any payment directly to Nevada Eye Consultants. I further authorize to them, any surgical and/or medical benefits otherwise payable to me for services. My consent is granted to use this original or a copy as effective and valid as the original.
  THANK YOU, Please submit only once →