Insurance Verification Form

DOB:
   
   
   
 
   
Primary's DOB:  
   
 
 
   
 

   

MEDICAL FAMILY HISTORY

(Select Self, Mother, or Father if applicable)
 
 
   
Submission applies to acknowledgement of
Contact Lens Care and Policy provided in the office

I, the patient/guardian/responsible party, have accurately and truthfully completed the information listed on the form. I acknowledge and authorize usage of my insurance coverage for services provided in the facility. I agree that all fees incurred are my responsibility regardless of insurance coverage. I acknowledge that I have reviewed the “Notice of Privacy Practices” regarding the use and disclosure of my health information.