Returning Patient Form

Patient Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
Email*
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Do you have insurance?
- Yes
- No
We offer a 20% discount to our cash-paying patients!
Please upload a copy of your medical and vision insurance cards. Note: VSP may not have its own card, please use your medical card.
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Max. file size: 2 MB.
Read through our HIPAA Policy Form here.

Patient Care Plan
We are committed to providing you with a great customer experience and are happy to verify insurance eligibility and benefits. However, this is never a guarantee of benefits as some insurance companies arbitrarily select certain services that they will not cover and/or must be medically necessary. It is your responsibility to understand the scope and limitations of your insurance policy and you are financially responsible for all charges rendered whether or not paid by your insurance. We are happy to discuss insurance coverage in more detail with you regarding your specific vision and/or medical plan.
*
- I acknowledge that I have had the opportunity to read over both the HIPAA Policy and Patient Care Plan of Blink Eyecare and agree to their terms.
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Today's Date*
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Hours

Phone: 509-828-4561

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