Insurance Information printable pdf download

INSURANCE INFORMATION

* Please give insurance card(s) to receptionist to copy

Patient’s Name__________________________________________________________ Patient’s Date of Birth____________________

Primary Vision Insurance:

Medicare

VSP

Spectera

Ace Hardware

OSF

Member Name ________________________________________________________ Member’s Date of Birth____________________

Member Address __________________________________________City _______________________ State ____ Zip ____________

Member ID# ___________________________________________ Member Social Security # _______________________________

Primary Medical Insurance: __________________________________________________________________

Member Name ________________________________________________________ Member’s Date of Birth____________________

Member Address __________________________________________City _______________________ State ____ Zip ____________

Member ID# ___________________________________________ Member Social Security # _______________________________

Supplement Insurance: ______________________________________________________________________

Member Name ________________________________________________________ Member’s Date of Birth____________________

Member Address __________________________________________City _______________________ State ____ Zip ____________

Member ID# ___________________________________________ Member Social Security # _______________________________

I certify that the information given by me in applying for insurance and/or Me d i c a re payment is true and corre c t .

I authorize my doctor to act as my agent in helping me obtain payment of my insurance and/or Me d i c a re bene-

fits, and I authorize payment of these benefits directly to Eyesite Illinois Va l l ey , LLC, on my behalf for any serv-

ices and materials furnished. I authorize any holder of medical information about me to release to the Center for

Me d i c a re and Medicaid Se rvices and/or my insurance company and it’s agents any information needed to deter-

mine these benefits payable to related services. If I have other health insurance coverage (as indicated in Item 9

on the CMS-1500 claim form or electronically submitted claim), my signature authorizes release of the above

medical information to the insurer or agency shown, and authorizes my doctor to act as my agent, as above .

X ___________________________________________________________

____________________________

LIFETIME PATIENT SIGNAT U R E

D AT E

WAIVER OF LIABILITY FOR REFRAC T I O N

I have been informed that the charge being made for the refraction portion of the eye exam is a charge that is not cove re d

by Me d i c a re .

X ___________________________________________________________

____________________________

S I G N AT U R E

D AT E

K. Ku nkel, O.D.

B. Ku nkel, O.D.

Apple Press - Peru, IL Waiv Rev 08-0045-21

Insurance Information