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Nic Zip African American Asian Other IN CASE OF EMERGENCY Name Home Phone Relationship Work Phone FINANCIAL RESPONSIBILITY Who is responsible for this account? Relation to patient Birthdate Social Security Number The responsible party is responsible for payment in full of all services or charges rendered by Joslin Eye Center, P.C. reguardless of insurance coverage. Please remember that most insurance companies do not cover all charges in full. Since insurance is a contract between you and.

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