Insurance Information Form

 

Insurance Policy

In order to accommodate the need and requests of our patients, we participate in numerous insurance programs. While we are pleased to be able to provide this service to you, it is impossible for us to monitor all the individual requirements of various plans. Insurance can be filed only if CFS is a provider with your insurance/ vision plan.

  • It is your responsibility to contact your insurance company to verify that our doctors are participating physicians with your insurance plan. It is probable that our doctors may participate in only some plans of a particular carrier but not in all of them.
  • It is your responsibility to give CFS current/correct insurance information so that we may obtain pre- certification for surgery. If you fail to do so, you are responsible for payment in full.
  • It is your responsibility to read and understand your own insurance policy. Certain services and procedures may not be covered depending on your own insurance policy.
  • It is your responsibility to obtain a referral should your insurance policy require specialist referrals.

 

We will bill you directly for all charges related to your office visit, if:

  • Insurance coverage is not in effect because we are not participating physicians in you plan, and/or
  • Insurance coverage is not in effect on the date of your visit, and/or
  • A non-covered service is performed or denied for the reason "not medically necessary" or the service is applied to your deductible.
  • An additional 27% charge will be added to any balance that is turned over to an outside collection agency. 

 

Please fill out and submit the form below.

Note: Front Office personnel will need copies of current insurance cards in order to process your insurance claim properly. List your primary insurance company first. 

Primary Insurance Company
*Indicates a required field.
Policy Holder Name (if other than yourself)
Policy Holder Name (if other than yourself)
Secondary Insurance Company
Policy Holder Name (if other than yourself)
Policy Holder Name (if other than yourself)
Billing
Yearly exams at Center For Sight (CFS) will be billed through your Medical Insurance unless instructed otherwise. *
Choose one.
Patient Signature
Date *
Date