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Patient Information Form

  • Date Format: MM slash DD slash YYYY
  • PRIMARY INSURANCE CO.

  • Date Format: MM slash DD slash YYYY
  • SECONDARY INSURANCE CO.

  • Date Format: MM slash DD slash YYYY
  • ADDITIONAL INFORMATION

  • REFERRALS PROCESS

    You are responsible for obtaining any referrals if your policy deems them necessary.

    WE CANNOT BE RESPONSIBLE FOR CLAIMS THAT ARE REJECTED BECAUSE A REFERRAL WAS NOT OBTAINED BY YOU. PLEASE FOLLOW THE GUIDELINES SET BY YOUR INSURANCE COMPANY REGARDING REFERRALS TO SPECIALISTS.
  • Please read the following information carefully:

    Since the terms of coverage are an agreement between YOU and your insurance company, questions and problems concerning your policy will need to be directed to your carrier. You are responsible for knowing the details of your coverage that includes what are covered and non-covered services. You are responsible for any co-payment or deductibles not covered by your insurance company. If you have no coverage, balance is due at time of service.

    Medicare and other insurance companies may not pay for the refractive part of the examination.  If refraction (the part of the exam that determines your need for eyeglasses) is necessary, Medicare and other insurance carriers may disallow it, stating that it is not a covered Medicare/Insurance benefit.  Therefore, the patient will be responsible for the refraction charge as well as for any other “non-covered” services under Medicare and any other private insurance plan.
  • Medical Release/Lifetime Signature on File/ Payment Authorization

  • Date Format: MM slash DD slash YYYY