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Patient Information Form

This section only applies if we're filing insurance for you:

Insurance #1


NOTE: Most insurance policies pay only a portion of your total charges. If you have any questions about your coverage, please contact your representative. We do not guarantee the accuracy of benefit information given to us by insurance companies. Please understand that financial responsibility for your account is yours,not the responsibility of your insurance company I authorize the release of any medical or other information necessary to process insurance claims. I authorize payment of medical or vision benefits either to the physician or supplier of services rendered or to myself if the provider does not accept assignment. I understand that I am responsible for any balance my insurance does not pay.

Please email or fax this form along with a copy of the front and back of your insurance cards. Schedule@HobsonEye.com or fax to 770-424-8284

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