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Becker Eye Care

Welcome to our office!
  • Patient Information

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  • Responsible Party

    (Only if Patient is a Minor)
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  • Insurance Information

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  • I hereby authorize any necessary treatment by the Optometrist in the practice of Becker Eye Care, LLC and further authorize Becker Eye Care, LLC to file a claim with my insurance(s) providing I have coverage for the services rendered.
    I understand that I am responsible for my bill and any collection fees made necessary to collect payment of services and/or products provided in the event that I do not have the required coverage or the insurance claim is denied, I further authorize the office of Becker Eye Care, LLC to release or obtain any required medical information from my attending physicians or any medical facility.

    Copays are due at the time of service.
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