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Advanced Vision Family Eye Care 1633 Birchwood Ave. Ste. 105 Bellingham, WA 98225 T (360) 5260075 F (360) 7339150PATIENT FINANCIAL INFORMATION SHEET Name of Patient: DOB: Insurance Subscriber: DOB:
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Fill in the patient's personal information, including their full name, date of birth, and contact information.
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Provide the patient's insurance information, including the name of the insurance provider, policy number, and group number.
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Specify the patient's primary care physician and any other healthcare providers involved.
05
Indicate the patient's medical history, including any existing medical conditions and medications they are taking.
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Document the patient's financial information, such as their annual income, employment status, and any outstanding medical bills.
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It is a document that contains financial information about a patient.
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The document can be filled out by providing accurate financial information about the patient.
The purpose of the document is to gather information about a patient's financial situation for billing and payment purposes.
Information such as patient's insurance details, payment arrangements, and any outstanding balances must be reported on the document.
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