Most people have both vision and medical insurance.  They are very different in the terms of the services they cover, and it is important to understand those differences.  Vision coverage is mainly designed to determine a prescritption for glasses, help pay for glasses or contacts, and to screen for medical conditions.  It is not designed to be used for medical condtions, diagnostic or screening tests or treatment plans.   Some medical plans have a vision benefit.

When a medical diagnosis or condition is present (such as diabetes) or an eye disease(such as infections, dry eye, allergies, cataracts etc), it is necessary to file the claim for your visit to your medical plan and the co-pays, co-insurance, non-covered services and deductibles apply.  Vision insurance does not cover medical eye problems. Our office does not make the rules; they are defined by insurance carriers and we are required to follow them.

In most cases, it is difficult to know prior to examination which type of insurance will apply or with whom our office will be able to file a claim for you.  We make every effort to determine as much information for you in advance.  We require you present both your vision(if you have one) and medical insurance cards at check in.

I understand the paragraphs above and authorize Vision Source to file a claim on my behalf, and I understand that I am responsible for any co-pays, co-insurance or deductible not yet met. 

Insurance Service Waiver:  I authorize the release of all medical information necessary to process insurance claims pertaining to my medical care or information necessary to process vision plan claims. As a member of  my individual insurance plan, I understand that I am liable for all costs associated with my office visit if:

• I am either not eligible
• The service rendered is a non-covered benefit
• A referral is needed from my primary care physician and not obtained
• The procedure does not meet the Medical Technology Assessment Guidelines.
• Any portion of the exam or additional testing is charged to my deductilbe, or if there is a copay that was unaware of a time of visit. 

Signature on file:  I certify that the information given by me in applying for payment under title XVIII of the Social Security Act is correct.

(x)  I authorize use of this form on all my insurance submissions

(x)  I authorize release of information to all my Insurance Companies.

(x)  I authorize my doctor to act as my agent in helping me obtain payment from my Insurance Company.

(x)  I authorize payment direct to my doctor or group practice

(x)  I permit a copy of this authorization to be used in place of the original

(x) I permit text and email to be sent to the number on file

Acknowledgement of Review of Notice of Privacy Practices:

I acknowledge that I read a copy or have been offered a copy of the Vision Source Notice of Privacy Practices, which explains how my medical information will be used or disclosed.