Friedrichs Family Eye Center Optometry - Martinsville

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • INSURANCE: Please present your insurance ID at each visit, it is the responsibility of the patient to make accurate and detailed insurance information available to us to enable processing of his or her insurance claim. The patient is to be considered self-pay until this information is provided to us.

    All co-payments and non-covered services are due at the time of service. Self-pay patients are responsible for payment in full at the time of services.

    REFERRALS/AUTHORIZATIONS: It is the responsibility of the patient to obtain a referral from his or her primary care physician prior to the scheduled visit if a referral is required. If a referral is not obtained, the patient accepts full financial responsibility for all services rendered.

    Insurance Authorization for Assignment of Benefits – I hereby authorize and direct payment of medical benefits to Friedrichs Family Eye Center on my behalf for any services furnished to me by its providers.

    Vision and Medical Coverage - There are two types of insurance benefits that will pay for services and products. You may have both and our practice may accept both. Vision care plans only cover well visits, may have a co-pay and allow discounts on materials. They DO NOT cover diagnosis, management or treatment of eye disease, eye allergies or eye injuries. In the event that you have any eye health problems or a systemic health problem that has ocular (eye) complications, your medical insurance will be utilized for the services provided.

    Authorization to Release Records – I hereby authorize Friedrichs Family Eye Center to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care, all information, including diagnosis and the records for any treatment or examination rendered to me needed to substantiate payment for such medical services as well as information required for precertification, authorization or referral to other medical provider.

  • Signature of Patient, Authorized Representative or Responsible Party
  • Date Format: MM slash DD slash YYYY
  • Type name of Patient, Authorized Representative or Responsible Party
  • Acknowledgement of Privacy Policy

    I acknowledge that I was offered a copy of the Notice of Privacy Practices for this office.

  • Date Format: MM slash DD slash YYYY
  • Do You or Anyone in Your Family have any of the Following Medical Conditions?