TSO Stone Oak

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  • Patient Medical History

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  • Medical & Vision Insurance Information

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  • Benefits Insurance Form

    There are two types of health insurance that will help pay for your eye care services and products. You may have both and Texas State Optical-Stone Oak accepts most insurance plans in both categories.

    Vision care plans only cover routine vision exams along with eyeglasses and contact lenses. Vision plans only cover a basic screening for eye disease. They do not cover the diagnosis, management, or treatment of eye health problems.

    Medical insurance must be used if you have any health problems or systemic health problems that have ocular complications. This is determined based on your diagnosis. Examples of a medical diagnosis are as follows: dry eyes, red eyes, blepharitis, allergies, elevated eye pressures, cataract, floaters, optic nerve disorder, diabetes, anytime the doctor prescribes medication, etc.

    If you have both types of insurance plans it may be necessary for us to bill some services to one plan and other services to the other. We will use coordination of benefits to do this properly and to minimize your out-of-pocket expense.

    We will bill your insurance plan for services if we are a participating provider for that plan. We will try to obtain advances authorization of your insurance benefits so we can tell you what is covered. If some fees are not paid by your plan, we will bill you for any unpaid deductibles, co-pays, or non-covered services as allowed by the insurance contract. Amounts not covered or paid by insurance are your responsibility. If not paid in full you will be liable for any accounting, late fees, and collections in the event of non-payment.

    Please provide your insurance cards to your appointment so we can make a copy. We need to have your medical insurance card or Medicare card on file in case we should need it in the future for billing your insurance.

  • I have read and understand the policies above. (Patient signature, parent if child.)
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