Patients must provide insurance card prior to exam
Individuals with whom we may share medical information
Financial Agreement / Authorization to Treat
Financial Agreement: I understand that I am responsible for payment of covered and noncovered services (as quoted by the insurance company). In cases where professional goods and services are not covered(denied) by your insurance company, it will be the patient's responsibility to pay for these services. I understand Professional EyeCare Associates may release my information to process all claims for reimbursement on my behalf.
Authorization to Treat: I authorize Professional EyeCare associates to furnish optometric care and services, including but not limited to: diagnostic tests, examinations, and other procedures which are deemed necessary in the course of my care.
Notice of Privacy Practices: I acknowledge, by my signature below, that I have been given the opportunity to review the Notice of Privacy Practices and I understand that I may request a copy of this notice should I so choose.
Please complete this form as accurately and completely as possible.
Please indicate if you (the patient) or a family member ever had the following conditions: