Personal Information

Employer / Student Information

Insurance Information

• I have reviewed the information on this form and it is accurate to the best of my knowledge.  I understand that this information will be used by the Doctor to help determine appropriate treatment.  If there is any change in my medical status, I will inform the Doctor.
• I authorize my insurance company to pay English Rows Eye Care all insurance benefits otherwise payable to me for services and/or materials.
• I understand that a quote of eligibility and benefits from my insurance company is not a guarantee of payment.  All benefits are subject to eligibility, medical necessity and the terms, conditions, limitations and exclusions of my health benefit plan at the time services are rendered and that I am financially responsible for all co-pays, co-insurance and non-covered charges.
• I authorize the use of this signature on all insurance submissions.
• I authorize English Rows Eye Care to release all information necessary to secure the payment of benefits.
• I acknowledge that I was offered/provided a copy of English Rows Eye Care’s Notice of Privacy Practices.