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Patient Information Sheet

Patient Information Sheet

Please print or type all information. Form must be signed and dated each year.
For assistance, please call 855-734-2020.

"*" indicates required fields

Are you a resident of the state of Florida?*
MM slash DD slash YYYY
Marital Status*
Are you currently employed?*
We will bill your insurance for you. Please provide us with the cards and indicate which is your PRIMARY coverage. LIFETIME SIGNATURE AUTHORIZATION I understand and agree that, regardless of deductibles and my arrangements with my insurance carriers, I am ultimately responsible for any balance on my account for any professional services rendered. I request that payment of authorized Medicare benefits be made either to me or on my behalf to Quigley Eye Specialists for any services furnished to me by that physician. I authorize any holder of Medicare information about me to release to the C.M.S. and /or Private or Secondary Insurance Company and its agents any information needed to determine these benefits or benefits payable for related services. NO HIDDEN CHARGES: IT IS OUR OFFICE POLICY THAT THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS THE RIGHT TO REFUSE TO PAY, CANCEL PAYMENT OR BE REIMBURSED FOR PAYMENT FOR ANY OTHER SERVICE, EXAMINATION OR TREATMENT WHICH IS PERFORMED AS A RESULT OF AND WITHIN 72 HOURS OF RESPONDING TO THE ADVERTISEMENT FOR ANY FREE. DISCOUNTED FEE OR REDUCED FEE SERVICE, EXAMINATION OR TREATMENT. I have been given a copy of Quigley Eye Specialists Notice of Privacy Practices to review and acknowledge by signing below.
MM slash DD slash YYYY
You have the right to receive a copy of signed authorizations upon request.

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