• Patient Information & Insurance Information

  • Patient Information

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  • Billing Information (Responsible Party)

    Fill out if different than Patient Information.
  • Vision Insurance Information

    Note: We participate with VSP and most self-funded Vision Plans as an In-Network Provider. We are Out-of-Network Providers for all other Vision Insurance plans.

  • Medical Insurance Information

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  • Routine vision exams will be filed with a patient's vision plan if one is available and we participate. A routine vision exam means there is a vision diagnosis, in the absence of a medical diagnosis. Vision diagnoses include myopia (near-sightedness), hyperopia (far-sightedness), astigmatism, and presbyopia.

    If a Medical Diagnosis (cataracts, glaucoma suspect, foreign body, diabetes, dry eye, etc) is determined by the doctor, the patient's exam is no longer routine, but medical. This means we will bill your medical health insurance and collect your medical copay and/or deductible which is required at time of service. We request a copy of your medical card in your chart for this reason.

    Please take photos of front AND back of insurance card OR scan and upload images of both sides of your insurance card below:

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    • I understand my insurance may pay less than the actual billed amount for services. I agree to be responsible for payment of all services rendered on my behalf or on the behalf of my dependent.
    • I give Richland Eye Care permission to bill my insurance for eye care services and/or products. I hereby authorize my insurance benefits to be paid directly to Richland Eye Care.
    • By signing below, I agree that I have read and understand all of the above information. This signature will also serve as record of my "Signature on File" that insurance companies require for claim processing.
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  • Acknowledgment - Receipt of Notice of Privacy Practices

    By signing this form, you are acknowledging that you have been offered a copy of Richland Eye Care's Notice of Privacy Practices, effective 2020:
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