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Located next to South Branch Library on Maysville Pike in South Zanesville, OH

Call Us Now: 740-836-6333

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Home » Contact Us » Patient Registration Form

Patient Registration Form

  • lnsurance lnformation


  • Please read and sign below: I authorize Nicole Whitaker OD to act as my agent in helping to obtain payment from my insurance company. I authorize payment directly to my doctor, and I permit this form to be used as my "Signature on File" for all my insurance submissions. I authorize release of any information needed to obtain payment to my doctor. I understand that I am responsible for payments to Nicole Whitaker OD, regardless of my insurance coverage. I understand that in the event my insurance company denies payment, I am responsible for the balance in full. I am aware that I am responsible for any copayments and/or yearly deductible as specified under my insurance contract. Exam fees and copays are non-refundable.
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  • *Please Note: Payment for examination and 1/3 of materials charge is due today. The balance is due on the date of dispensing. You may have a copy of your refractive prescription on completion and payment of our services. Thank you very much for your kind cooperation.