Thank you for choosing to fill out paperwork prior to your appointment. Doing so will allow us to serve you more efficiently, making your appointment faster and safer for you and our staff.

Please have your insurance information ready. If you cannot provide it below, plan to arrive ten minutes early to your appointment and bring your insurance card so we can process your information.

If you have any questions, feel free to contact us at 916-726-1818.
Thank you again for your cooperation. We look forward to seeing you at your appointment.

Patient Check-In Forms

Step 1 of 3

Appointment Location*
Appointment Date*
MM slash DD slash YYYY
Patient Name*
First Last
Financial Agreement
If I do not have applicable insurance benefits, I acknowledge that I am responsible for all charges incurred at EYEcenter Optometric, which are due on the date services are rendered. I hereby assign and request that payment of all insurance benefits be made directly to EYEcenter Optometric for services and materials furnished to me by EYEcenter Optometric and request that they submit claims for payment for those services on my behalf to my vision and/or medical insurance carrier(s). I understand that there is no guarantee of payment from any insurance company or other payer. I understand that I am fully responsible for any co-payments, deductibles, co-insurance or any services and/or materials, which are denied by my vision, or medical insurance after a claim is processed. We will attempt to confirm your insurance coverage prior to your treatment. It is your responsibility to provide current and accurate insurance information, including any updates or changes in coverage prior to your appointment. Should you fail to provide this information, you will be financially responsible.
- I certify that I have read and fully understand the above statement and consent fully and voluntarily to its contents.
I hereby authorize the release of my medical records to third party insurers or authorized persons to whom disclosure is necessary to establish or collect a fee for the services provided, such as billing or insurance payers. I understand that I am financially responsible for all charges incurred if I do not authorize release. DIVORCED PARENTS / SHARED CUSTODY OF MINORS: EYEcenter Optometric will communicate about treatment and payment with the parent present at the time of the minor's visit. By signing below, I acknowledge that the adult who signs for a minor child on the day of service accepts full responsibility for payment.
- I certify that I have read and fully understand the above statement and consent fully and voluntarily to its contents.
I understand that I am responsible for a $25 returned check fee. If payment is not received for services or materials rendered, your account will be placed with a collection agency.
- I certify that I have read and fully understand the above statement and consent fully and voluntarily to its contents.
Consent
I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

EYEcenter Patient Check In Forms

Patient Check-In Forms

Step 1 of 3

Financial Agreement

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EYEcenter Optometric

EYEcenter Optometric

EYEcenter Optometric

EYEcenter Optometric

EYEcenter Optometric

Patient Check-In Forms

Step 1 of 3

Financial Agreement

Ask Here, Voice Search

EYEcenter Optometric

EYEcenter Optometric

EYEcenter Optometric

EYEcenter Optometric

EYEcenter Optometric

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