Patient Name*

Prefix First Last

Date of Birth

Social Security #

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Sex

Male
Female

Status

Single
Married

Home Phone

Work/Cell Phone

Email*

Occupation

Is Patient Condition Related To:

Employment? (Current or Previous)
Auto Accident?
Other Accident?

PRIMARY INSURANCE CO.

Insurance Name

ID or Policy #

Group #

Policy Holder

Relationship To Patient

Female
Male

Date of Birth

Address (if different from patient’s)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

SECONDARY INSURANCE CO.

Insurance Name

ID or Policy #

Group #

Policy Holder

Relationship To Patient

Female
Male

Date of Birth

Address (if different from patient’s)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

ADDITIONAL INFORMATION

Primary Care Physician

Phone

Primary Pharmacy

Phone

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

I authorize payment for all Medicare and/or other insurance benefits for services rendered by this office be made payable to the doctors in this office. I authorize this office to release to the Centers for Medicare and Medicaid and its agents or any other insurer any information necessary to determine the benefits payable for related services. I permit a copy of this authorization to be used in place of the original. This form will serve as a lifetime signature form. I have read and understand the information given to me on this form. I authorize this office to release information to complete my insurance claims.

• I understand and agree to pay for services that are considered cosmetic and/or not medically necessary by my insurance company.
• I understand that verification of benefits is never a guarantee of payment from my insurance.
• I understand that I am responsible for any collection charges, interest and/or fees if I do not remit payment on “non-covered” services.
• In the event of nonpayment I will be responsible for any legal or collection fees. The collection fee is a percentage of the total balance turned over to an outside agency. I agree to be responsible for these fees.
• I understand that my eyes may be dilated during examinations.
• I hereby give consent for myself or my child to be seen

Signature*

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Date