Family Vision Care Intake Form

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  • We will be happy to submit to your insurance for your visit. It is your responsibility to know if your insurance covers the type of office procedures performed and whether referrals are necessary.

  • I am responsible for all fees, referrals, co-pays, deductibles and non-covered procedures and devices provided. I authorize Family Vision Care to submit to my insurance and assign the benefits to be directly paid to the doctors of Family Vision Care when applicable. I understand that Family Vision Care is fully compliant with HIPAA regulations and privacy issues. I request my professional records/reports only to be released to Family Vision Care when necessary and to release my records to other doctors/professionals who may provide care for me in the future.

  • Date Format: MM slash DD slash YYYY