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Stonebridge Eye Care
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Patient Paperwork

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  • Eye Examination History

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  • Eye Health History

  • General Health History

  • Family Medical History

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  • Social History

  • Major Medical and Vision Insurance Information

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  • Major Medical Insurance Information

    This information is required to complete any insurance claims on the patient’s behalf. Information submitted here must be current, accurate, complete and legible in order for the appropriate claim to be submitted. If you have any questions about completing this section, please ask the front desk staff member for assistance.


    This information is required and must be correct in order for our office to file your claim.

  • Vision Insurance Information

  • I HAVE COMPLETED THIS INFORMATION PACKET AND UNDERSTAND THAT INCORRECT OR FALSE INFORMATION MAY RESULT IN UNPAID CLAIMS. I UNDERSTAND THAT I AM RESPONSIBLE FOR UNPAID CLAIMS. I ALSO UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT AT THE TIME SERVICES ARE RENDERED AS WELL AS APPLICABLE COPAYMENTS AND FEES APPLIED TO DEDUCTIBLES. I AGREE TO PAY FOR ALL BILLED SERVICES AND MATERIALS TODAY. I UNDERSTAND THAT I AM RESPONSIBLE FOR SERVICE AND MATERIAL FEES IF DR. WRIGHT IS NOT A PROVIDER FOR MY INSURANCE. I UNDERSTAND THAT IF I AM THE RESPONSIBLE PARTY FOR A MINOR PATIENT THAT ALL OF THE ABOVE SAID STATEMENTS ARE MY RESPONSIBILITY. MY SIGNATURE BELOW INDICATES I HAVE READ AND AGREE TO THESE STATEMENTS REGARDING THE BILLING AND PAYMENT FOR MY CARE AND SERVICES PROVIDED AT THIS OFFICE.

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  • Acknowledgement of Receipt of Privacy Policy

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  • Permission to Leave Telephone Messages

  • Permission to Share Personal Health Information

  • Listed below are the names and phone numbers of individuals for whom I am giving permission to access information or materials from this office which pertain to me, my health status, my personal health record and all other information contained within this office or its electronic data base.

    (Our office is required to offer this option and to abide by your wishes.)

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