Watts Eye Associates Insurance

Dear Patient:

Thank you for choosing Watts Eye Associates! Our mission is to deliver the highest quality of eye care you will ever receive. As a courtesy, Watts Eye Associates will be happy to bill your insurance company for your visit with us. Please understand that this is your insurance policy, not ours. Please read our insurance policies, sign and date the bottom. By signing, you agree to pay your claim if for any reason your insurance company denies it.

Insurance Cards

Please have your card with you so we can copy all the necessary information. This will make the billing process easier for all of us. If your insurance should change in the future, please inform the office prior to your next visit.

Co-Pays

Have your payment ready when checking in at the front desk. This is a contractual obligation with you insurance company for which you are responsible and it is mandatory that we collect it from you.

Referrals

As a member of an HMO, you have become a partner with your Primary Care Physician and it is mandatory that you get a referral from your Primary Care Physician to see a specialist. Optometrists are considered specialists. We require referrals for all visits that are not routine in nature, i.e. itchy red eyes, an injury to your eye(s), seeing light flashes or floaters, and so on. If possible, obtain multiple visits in your referral so you do not have to repeat this process if we need to see you more than once. If a referral has not been obtained and the claim is denied, you will be responsible for payment in full.

Insurance Benefits

There are many insurance companies and many plans within insurance companies. Therefore, it is in your best interest to verify your benefits. Know your deductible amounts and confirm that Dr. W. F. Watts, Dr. C. E. McDonald, or Dr. K.D. Sullivan is listed on your insurance companies provider list. Please also verify that you do not need a prior authorization for your visit. Many Vision programs do not issue their own insurance cards so it is crucial that you are aware of your Vision Program prior to your visit as your health insurance card will not inform us of separate vision programs.

Worker's Comp

We do not bill Worker’s Comp. cases. Payment is expected in full at the time of the visit. We will be happy to assist you in any paperwork or forms that need to be filed.

Self-Pay

Payment is made in full at the time of the visit.

Our staff will be happy to assist you through any of the processes listed above. We understand that insurance policies and programs can be quite confusing. Your patience and understanding will be greatly appreciated in helping to resolve any problems.*

First Last

Please type and sign your first and last name to acknowledge that you have read the policies included in this form.

Date of Birth*

Signature*

If you are under the age of 18, we require the signature of your parent or legal guardian.

Insurance Information

Medical Insurance Name

(i.e. Blue Cross Blue Shield, Tufts)

Insurance ID #

If you are a member of one of the following Vision Programs, please select:

VSP
EyeMed
Avesis

VSP Subscriber Name

VSP Subscriber Date of Birth

Last 4 Digits of SSN