Patient-Information

Emergency Contact:

Current Medications (RX or over the counter)

1. Vision care plans (such as VSP, Davis, Spectera, Avesis, etc.)

• Vision care plans only cover routine vision exams along with eyeglasses and contact lenses.
• They do not cover diagnosis, monitoring, management or treatment of eye diseases or visits resulting in prescription medications.

2. Medical insurance (such as Blue Cross Blue Shield, Presbyterian, United Health Care and Medicare)

• Medical insurance must be used if you have any eye health problems or systemic health issues that are associated with ocular complications (such as diabetes, use of high risk medications and prior eye surgeries).
• 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 or separate the services on different days. VSP does allow coordination of benefits to minimize your out-of-pocket expense.
• We will bill you for any unpaid deductibles, co-payments or non-covered services as allowed by the insurance contract

Assignment and Release: I hereby authorize third party or insurance payments to be made directly to Accent on Vision and fully understand that I am the responsible party for all fees incurred by me at the above mentioned facility. I also authorize the release of any information required for the processing of those claims.