4-Insurance Information Patient Details

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4-Insurance Information MEDICAL INSURANCE COVERAGE

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4-Insurance Information Primary Medical Insurance

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  •  No. Please select NO and Next at the end of each Medical Insurance section
  •  Yes, Please complete this section
  •  YES, Please complete the Secondary Medical Insurance Section
  •  NO, Please select No and Next at the bottom of each Medical Insurance section

4-Insurance Information Secondary Medical Insurance

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  •  YES, Please complete the Tertiary Medical Insurance
  •  NO, Please select No and Next at the bottom of each Medical Insurance Section

4-Insurance Information Tertiary Medical Insurance

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  •  YES, PLEASE CALL OUR OFFICE
  •  NO, Please click next at the bottom and complete the Vision Insurance Section

4-Insurance Information VISION INSURANCE COVERAGE

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4-Insurance Information Primary Vision Insurance

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  •  YES, PLEASE COMPLETE ALL FIELDS IN THIS SECTION
  •  NO, Please select NO at the bottom of the Tertiary Vision Section
  •  Yes, Please complete the Secondary Vision Insurance section
  •  NO. Please click no and next at the bottom of each Vision Insurance Section

4-Insurance Information Secondary Vision Insurance

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  •  YES, PLEASE COMPLETE THE TERTIARY VISION COVERAGE SECTION
  •  NO. Please click no and next at the bottom of each Vision Insurance Section

4-Insurance Information TERTIARY VISION COVERAGE

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  •  YES, PLEASE CALL OUR OFFICE
  •  NO, there is no additional MEDICAL or VISION insurance coverage

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