Optometrist in Escanaba, MI
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Name
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Last
Phone #
Date of Birth
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Relationship to patient
Insurance Information
Name of primary insurance company
Name of supplimental insurance company
I consent to treatment necessary for the care of the above named patient.
I authorize the release of all medical records to the referring and family physicians and to my insurance company, if applicable.
I allow fax transmittal of my medical records, if necessary.
I take full financial responsibility for services rendered by Dr. Kohli or Dr. Inverson.
I understand that payment of charges incurred is due at the time of service unless other defined financial arrangements have been made.
I agree to pay all reasonable collection costs in the event of default payment.
I further authorize and request as a one time signature that insurance payments be made directly to U.P. Ophthalmology until otherwise stated.
By signing this statement i have consented for treatment, financial responsibility, release of medical information, and insurance authorization as long as I am under the care of U.P. Ophthalmology.
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Office Hours
Day
Mon
day
8:00am
4:00pm
Tues
day
8:00am
4:00pm
Wed
nesday
8:00am
4:00pm
Thurs
day
8:00am
4:00pm
Fri
day
8:00am
3:00pm
Sat
urday
Closed
Sun
day
Closed