New Patient Demographics

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Primary and Secondary Insurance Information

PLEASE PROVIDE A COPY OF ALL INSURANCE CARDS AND DRIVER’S LICENSE

I hereby authorize all insurance benefits to be paid directly to THE RETINA PARTNERS. I understand that I am responsible for charges as designated by my insurance companies (e.g., deductibles, co-payments, etc.) I am also responsible for all charges not covered by insurance and for any finance fees incurred on unpaid balances. I authorize THE RETINA PARTNERS to release any information to my insurance company when requested by them.

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