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  • Acknowledgement of understanding of the "Notice of Privacy Practices"

    I understand I may ask for a copy of the "Notice of Privacy Practices" for my record and that I otherwise understand the "Notice of Privacy Practices."

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  • Insurance Authorization

    I hereby assign all payments of benefits to BayState Eye Center to which I am entitled for services rendered. I understand I am financially responsible for the copayment and any non-covered services at the time of service.

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