Consent Form - Eye Care Associates

Patient Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Date of Birth*

Email*

Enter Email Confirm Email

Insurance Name*

Member ID*

Policy Holder Name*

Policy Holder Date of Birth*

Employer Name*

Occupation*

If minor, name of parent/guardian

First Last

I authorize any holder of medical information about me to release to my insurance company and its agents any information needed to determine these benefits or the benefits payable for related services. I request that payment of authorized insurance benefits for any services furnished me, be made on my behalf to Eye Care Associates.
Any fees not paid by my insurance company will be my responsibility.
Unpaid patient balances past 30 days will incur a minimum late fee of$ 3.00 per 30 days if payments are not made.
Eye Care Associates will verify my benefits using information I provided. My insurance company does not guarantee any benefits paid to Eye Care Associates. I am responsible for knowing my benefits and selecting my healthcare provider, whether in or out-of-network.

This notice is to inform you that your health plan may not cover the fee(s) listed for the following reason(s):

The services are excluded from your plan
Prior authorization is required and has not been received or has been denied
Subject to insurance policy such as deductible, copay, or co-insurance .
Refraction, if paid on the same day of service we reduce the price from $75. 00 to $33.00. Otherwise it will be billed out the full price at $75.00
Screening Photos are$ 15.00
Contact Evaluation can range from $45.00 - $120.00 depending on if a new fit or a refit and choice of contact lens.

By signing I acknowledge that I have read and understand each statement and verify that all personal information is correct.

Signature*

Relationship to patient:*