Medical History Information

* If this is a work-related injury please provide all paperwork provided by your employer.

* When a referral is necessary to render treatment and has not been provided, your appointment will have to be rescheduled until it can be obtained.

* As a courtesy to you, we verify insurance benefits and coverage. This is not a guarantee of coverage or payment. We encourage you to read your benefits handbook if you have any questions or call the 800 number on your insurance card. Any and all charges not covered by insurance will be your financial responsibility. All in-network claims are submitted to insurance and paid directly to Whitsett Vision Group. You will be asked to pay for any co-pay, deductible or out-of-pocket expenses at the time of service. Out of network insurance claims must be paid at the time of service but we will file the claim to get you reimbursed.

* It is your contractual responsibility to provide us with insurance information prior to services being rendered. By denying insurance coverage information, you may waive the right to have WVG file a claim at a later date and waive discounted fees that you might have otherwise been entitled to.

* By submitting below, I authorize the release of any necessary information to my insurance company, which may be needed to process payment for my claim. I further acknowledge that I have been informed and agree with the above policies of Whitsett Vision Group.