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  • I hereby acknowledge that I received a copy of this office's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I may request a copy of any amended Notice of Privacy Practices at each appointment.

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  • It is customary to pay for all services on the date rendered unless other arrangements were made. The patient and the guarantor are responsible for all deductibles and co-pays at the time of the visit and any other fees in accordance with insurance contracts. The patient and guarantor are responsible for all elective or non-covered services and any services that are not considered medically necessary.

  • I authorize the release of any medical information necessary to process this claim and I request that payment of medical benefits be made directly to Westfarm Eye Associates. I hereby acknowledge that I am fully responsible for payment as listed above.

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