EmailMe Form - the eye gallery-insurance forms

Please give us pertinent information to verify and authorize your vision insurance.

Its a good idea to send this information prior to your scheduled appointment. This allows us ample time to authorize and verify your vision insurance benefits for your exam.

Q: Why is my SS # needed to authorize/verify my vision benefits?

A: Your employer initially sets up the authorization process with the vision insurance company ( i.e.: Eyemed, Spectera) . They may require your work ID, full SS# or last for of SS#.

Most employers are switching to other forms of verification, however most still utilize SS# as a form of authorization and verification.

We can verify your insurance on the day of appointment , however this may delay your scheduled appointment time. Please arrive 15 minutes prior to your appointment time. *

* Check to see if your company changed vision insurance provider form prior year.

(We may have a problem searching for you in the incorrect database )

Verify that you have you have enrolled in vision benefits for the year.

NEW PATIENTS: Photo Identification is required if you are utilizing Vision Insurance or Medical Insurance for your visit. This is for your protection and ours as well.

Name of Primary:
FOR VISION INSURANCE

Prefix First Last Suffix

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email

In order to receive patient invoices and clinical exam summary.

Date of Birth of Primary Policy Holder

MM / DD / YYYY

I don't have vision insurance.

Check Here

Primary Vision Insurance

Secondary Vision Insurance (if applicable)

Name of the primary for any additional VISION insurance.

Prefix First Last Suffix

Date of Birth of Primary Policy Holder

MM / DD / YYYY

Employer

Social Security # for Primary Policy Holder

Appointments scheduled for:

PRIMARY POLICY HOLDER

Dependent(s).

Primary policy holder and dependents.

Scheduled eye exams for dependents:

Name of Patient #1

First Last

Patient's date of birth.

MM / DD / YYYY

Occupation
Grade

Name of Patient #2

First Last

Patient's date of birth.

MM / DD / YYYY

Occupation
Grade

Name of Patient #3.

First Last

Patient's date of birth.

MM / DD / YYYY

Occupation
Grade

MEDICAL INSURANCE

Major medical may help pay for eye related issues of the eyes ( example: cataracts, diabetes, macular degeneration, acute red eyes, and dry eye problems)

MEDICAL INSURANCE INFORMATION

Yes, I have medical insurance

No, I don't have medical insurance

MEDICAL INSURANCE

Policy Number

Group Number

NO SHOW POLICY

If you need to cancel your appointment please notify us 24 hours prior to your scheduled appointment. Day of appointment cancellations are allowable.

A fee of 25$ will be assesed to your account for NO SHOW appointment.

We will Text, Call and/or E-MAIL you the day prior to remind and confirm your scheduled appointment at the eye galllery.

It is in your best interest to communicate any changes that you need in your scheduled appointment. This allows other patients to schedule that are in need of this appointment.

I agree to the eye gallery NO SHOW POLICY *

Check Here

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