*We must have a copy of all insurance cards on the day of service*

NOTICE OF PRIVACY PRACTICES: I/We have been offered a copy of Total Vision Family Eye Care statement on privacy practices.
AUTHORIZATION TO RELEASE INFORMATION: I/We hereby authorize Total Vision Family Eye Care to release any medical or incidental information that may be necessary for medical benefit of in processing applications for financial benefit. This includes but is not limited to my insurance company, Rehabilitation Services, Social Security Administration, and Worker’s Compensation.
CONSENT FOR TREATMENT: I/We hereby authorize Total Vision Family Eye Care to administer diagnostic and medical procedures as may be necessary for proper health care.
OFFICE POLICY ON PAYMENT: I understand that I am responsible for payment of all charges. As a courtesy, my insurance will be billed for me. It is my responsibility to pay any deductible, copay or any other balance not paid by my insurance company. I authorize insurance benefits to be paid directly to the provider.
VISION PLAN COVERAGE: I/We understand that only one vision plan may be used for exam/materials per visit-per patient and that the vision plan to be used must be chosen before the exam occurs and can not change at a later date. If I do not supply my vision plan at the time of services I will be required to pay up front and self-submit on my own.