Schedule an Appointment ‹ EyeWorks Optical Saint Paul Eye Glasses Clinic

Please complete the form below as fully as possible in preparation for your appointment.

If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

First Name *

Middle Initial *

Last Name *

Address 1 *

Address 2

City *

Zip / Post Code *

Phone *

Alternate Phone

Birthday *

Employer

Referred by

Relationship to the Insured

Hobbies

To help us address your visual needs, please list your work tasks & hobbies.

Primary Insurance Plan

ID #

Group #

Name of the Insured

As a courtesy to our patients our office will submit claims to any insurance company for which we are participating providers. Although we may have called for authorization prior to your exam, we are only given a general outline of benefits. Therefore, if there is a co-payment or you do not have routine vision coverage, you will be responsible for any balance left on your account after your insurance company has processed the claim.

Assignment of Benefits/Records Release: I hearby authorize payment of medical benefits to EyeWorks Opical for services rendered to myself and/or dependents. I fully understand that I am responsible for any co-payments or for the payment of the entire balance if, for any reason, my insurance company denies payment of the claim. I permit a copy of this authorization to be used in place of the original.

I also authorize the release of any information by EyeWorks Optical to my referring doctor, insurance company, or governing authority on behalf of myself and/or my dependents.