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Available Forms

Patient Information - Adult

Adult Patient Form

(if applicable)
(if applicable)

Emergency Contact

Insurance Information

Patients with no insurance must pay in full at the time of appointment. Estimated Co-pays or charges not covered by insurance are due at the time of visit. We are unable to bill your insurance without insurance cards and photo identification. We bill insurance as a courtesy. We will only bill your primary and secondary insurance. All fields are required in order for us to properly bill your insurance.

Primary Insurance

Secondary Insurance

Insurance and Financial Policy

You will be provided with an estimate of the anticipated charges of your care upon request.

Patients are responsible for any balance due if insurance does not pay for any reason. We will not become involved with any dispute you might have with your insurance company. Past due accounts may be subject to a 40% collections fee if referred to a collection agency.

I authorize the release of any medical information necessary to process all claims and I authorize the release of payment for vision/ medical benefits to Jan Nyboer, M.D.

Please be aware that we charge a $25 fee for no-show appointment.

I, the patient/guardian, have accurately and truthfully completed the above information and agree that all fees incurred are my responsibility regardless of insurance coverage. I certify that I have read and agree to the patient information and privacy policy of this office.

Please type your name as your digital signature
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