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Registration - Child

Please use this form to register minors prior to their first appointment. Our patient care coordinator will contact you shortly. If a required field does not apply, please type "N/A" for Not Applicable.

Patient Date of Birth:

Address:

Parents or Guardians:

Mother:

Father:

ALL INSURANCE CARDS AND VISION COVERAGE MUST BE PRESENTED BEFORE SERVICES ARE RENDERED. PROOF OF MEDICAL INSURANCE DOES NOT GUARANTEE PAYMENT BY THE INSURANCE COMPANY. PLEASE BE AWARE THAT:

1) MEDICAL INSURANCE DOES NOT COVER NON-MEDICALLY RELATED VISION EVALUATIONS.

2) VISION PLANS DO NOT COVER NON-ROUTINE OCULAR HEALTH (MEDICAL) SERVICES.

Medical Insurance Information:

RELEASE OF INFORMATION AND INSURANCE FILING:

I request that payment of authorized insurance be made to Dr. Samantha Slotnick for any services rendered. I authorize any holder of medical information about me, to release to HCF and its agents any information needed to determine these benefits payable for related services. I also understand there may be procedures that are not covered by my insurance and I am responsible for payment, including but not limited to refraction. I understand that payment in full is expected when services are rendered and materials dispensed.

HIPAA privacy acknowledgement - I was given and read, and understand my privacy rights under the HIPAA laws. (Copy available in Patient Forms area.)