About Your Insurance

Consent

I have read and accepted the policies.

There are two types of health insurance that will help pay for your eye care services and
products. You may have both types and Family Vision Center accepts most insurance
plans in both categories: 1) Vision Plans (such as VSP, EyeMed, and others) and 2)
Medical insurance (Blue Cross\Blue Shield, Medicare, and others).

Vision plans ONLY cover routine vision wellness exams, along with eyeglasses or
contact lenses. Vision plans DO NOT COVER MEDICAL EYEHEALTH CARE (the
diagnosis, management or treatment of eye health problems).

Medical insurance MUST be used for medical eyehealth care diagnoses, treatment
and follow up.

If you have both types of insurance plans it may be necessary for us to bill some
services to one plan and some services to the other. We will follow a procedure
called coordination of benefits when appropriate to minimize your out–of–pocket
expense.

If some fees are not paid by your insurance, we will bill you for them, such as
deductibles, copays, or non-covered services as allowed by the insurance contract.

Please provide your insurance cards to our staff members so we can make a copy. We
need to have your medical insurance card on file if we should need it in the future for
billing your insurance.

Patient Name(Required)

Patient signature (Parent if child)

Date

Please print and sign the insurance information form below, and bring it with you to

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