By submitting the the new patient form you are agreeing that you have been offered a copy of the View Patient Privacy Policy.
Insurance Financial Waiver
By submitting this New Patient I understand that the services and /or supplies provided by Grant Vision Care may not be considered eligible for benefits (e.g., they may be determined to be not medically necessary, non-covered or investigational).
I understand that my health/eye insurance coverage has certain restrictions and limitations, such as authorization requirements and non-covered services and/or supplies. Since I have chosen to obtain the services and/or supplies, I agree to be financially responsible for any and all related charges, if they are not covered by my insurance.
New Patient Page