Minimally Invasive Vision Correction In Virginia Learn More

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First Name

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Last Name*

Last Name

Date Of Birth*

Date Of Birth

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Primary Medical Insurance Name*

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Insurance Subscriber First Name*

Insurance Subscriber First Name

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Insurance Subscriber Last Name

Insurance Subscriber Date of Birth*

Insurance Subscriber Date of Birth

Relation to Patient*

Relation to Patient

Secondary Insurance Name

Secondary Insurance Member ID Number

Vision Insurance Name

Vision Insurance Member ID Number

Person authorized to receive/discuss medical and/or financial information*

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I understand that:*

Most medical insurance plans, including Medicare, do not cover routine refraction or routine eye examinations Our office fee for a refraction is $80.00 and this is collected at the time of service, in addition to any co-payment your plan may require. Should your plan pay us for the refraction, we will reimburse you accordingly.

Vision Plans:*

It is the patient’s responsibility to know if he/she has a vision plan AND what company it is with.

Managed Health Care Plans:*

If the patient does not have vision coverage, or is not eligible for a vision exam, then the patient is responsible for a referral from the primary care physician. If a referral is not received at the time of service, the patient will be financially responsible for all the care and services rendered at the time of service.

Payment:*

The patient is responsible for all charges, deductible payments, co-insurance and/or co-pay payments at the time of service.

Cancellations and Missed Appointments*

The patient is responsible for giving at least a 24 hour notice of any cancellation of his/her appointment. ALL MISSED APPOINTMENTS WILL BE CHARGED $30.

Consent*

I have read and understood the above office policies. I agree that I am financially responsible for any and all care that is not covered by my insurance policy.

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Dulles Eyes Associates was established to meet the challenges of modern eye care and eye surgery

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(703) 723-9633

Required form

Online New Patient Paperwork

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Required Before Appointment

Medical Release Form

HIPAA Policy

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