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HIPAA, Exam and Financial Acknowledgement Form

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This form contains brief acknowledgements for the patient to initial regarding the different policies in our practice that affect their care.

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$10.00

Data sheet

Pages 2
Customizable Yes

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We call this "The Form You Always Have to Sign" in our office.  It includes information regarding insurance, bill payment, HIPAA, examinations and fees, coordinated care, appointment times, refunds, dilation and Optomap, contact lens professional fees, and refractions.

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HIPAA, Exam and Financial Acknowledgement Form

HIPAA, Exam and Financial Acknowledgement Form

This form contains brief acknowledgements for the patient to initial regarding the different policies in our practice that affect their care.

Write a review

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Cool Springs EyeCare



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Cool Springs EyeCare
3252 Aspen Grove #1
Franklin, Tennessee 37067
United States