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Patient Intake

  • Date Format: MM slash DD slash YYYY
  • (last 4 digits only)
  • Date Format: MM slash DD slash YYYY
  • I authorize the staff or Doctors of Manhattan Vision Associates to leave voicemail messages for me, email me, or text message me regarding product status notifications (ex: glasses ready to be picked up), appointment reminders, test results, diagnoses and treatments.
  • INSURANCE INFORMATION

  • Insurance Authorization and assignment of benefits: I hereby authorize Manhattan Vision Associates to furnish insurance carriers any information concerning my condition and treatments, and I hereby assign to Manhattan Vision Associates all payments for services rendered to my dependants or myself. I understand that I am responsible for the amount not covered by my insurance.
  • Date Format: MM slash DD slash YYYY
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