Please complete the form below as fully as possible in preparation for your appointment.
To help us address your visual needs, please list your work tasks & hobbies.
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.
6575 Cahill Ave East, Suite 101, Inver Grove Heights, MN 55076
(651) 451.1100 • firstname.lastname@example.org