New Patient Registration Patient Details

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New Patient Registration Contact Information

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New Patient Registration Emergency Contact Details

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In Case of Emergency Notify:

New Patient Registration Insurance Information

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New Patient Registration Office Policy Regarding Payment

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We will file your insurance on your behalf for today’s visit. We accept Medicare assignment. Today you are responsible for paying deductibles, copays, as well as fees for non-covered services.

  •  Yes
  •  No

If other than a physician referral please check the one that best applies to how you heard about us.

  •  Magazine
  •  Facebook/Email
  •  Insurance
  •  Website
  •  Other

New Patient Registration Lifetime Signature Authorization

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In cases where private insurance and or Medicare claims are to be filed, the following form should be completed. In order for us to submit a claim on your behalf for services, we must have your authorization to release medical information.

I hereby authorize Bonita Vision Center to release all medical information and to submit insurance and other claims, including appeals, on my behalf and request payment of Medicare benefits either to myself or to the party who accepts assignment. I understand that I, the patient, am financially responsible for bills submitted and for any balance not paid by insurance. A copy of this signature is valid as the original.

I also give my permission for a report of my evaluation, treatment, and follow up evaluation to be sent to my referring physician and/or family physician.

I have read the above Office Policy and Lifetime Signature Authorization completely. I understand and accept the policy.

(Please click below to draw/upload sign)
(Your IP Address : IP:23.21.4.239 )

New Patient Registration Corona Virus Protection Form

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In order to protect the safety of our providers, staff, and patients; please provide answers to all of the following questions before coming in for your scheduled appointment:

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  •  No
  •  Yes
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  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
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  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
(Please click below to draw/upload sign)
(Your IP Address : IP:23.21.4.239 )

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