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Patient Information

Patient Employment Information

If the RESPONSIBLE PERSON and PATIENT Info is the same, Select "Self"

Responsible Person Employment Information

Do we accept your insurance? Most Likely ...but we still have to process it. Depending on your insurance provider, this process can be time-consuming while we try to get the approval necessary for us to proceed with your eyecare plan. Sometimes we find out that your insurance company may have a problem with your coverage that we can correct for you before you even enter our office! By completing this form online, we can take the guesswork out of the claim process for you and do all the processing work. We truly want to make your visit to our office a pleasant visit, so our experienced staff will go to work on getting the best coverage possible that you are entitled to by your insurance carrier.

Many times we find situations where your medical insurance and your vision insurance can be applied in conjunction with each other to better cover your needs, so if you have medical insurance please enter your medical insurance carrier information below.
OTHER INFORMATION - You may elaborate on any information below, and/or in the office