Patient Signature / Submit Data
ABOUT YOUR INSURANCE
There are two types of health insurance that will help pay for your eye care services and optical
products. You may have both types and Bakersfield Eye Care Optometric Center accepts most insurance
plans in both categories: 1) Vision plans (such as VSP, EyeMed and others) and 2) Medical insurance
(such as Blue Cross/Blue Shield, Medicare and others).
Vision plans only cover routine vision wellness exams, along with eyeglasses and contact lenses. Vision
plans do not cover medical eye care (the diagnosis, management or treatment of eye health problems).
Medical insurance must be used for medical eye care. If some fees are not paid by your insurance, we
will bill you for them, such as deductibles, co-pays or non-covered services as allowed by the insurance
Please provide your insurance cards to our staff member so we can make a copy. We need to have your
medical insurance card or Medicare card on file in case we should need it in the future for billing your
I have read and accept these policies.
ASSIGNMENT OF BENEFITS
I hereby assign all medical/vision benefits to which I am entitled, including Medicare, private
insurance, or any other health/vision plans to Bakersfield Eye Care Optometric Center. I hereby
authorize said assignee to release all information necessary to secure payment. This assignment will
remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as
valid as an original.
I understand that I am financially responsible for all charges not paid by my insurance, including
non-covered services, such as refraction and contact lens evaluations.
AUTHORIZATION FOR THE USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
I hereby authorize the use and disclosure of individually identifiable health information relating to
me, which is called Protected Health Information (PHI), under a federal privacy law. I further
understand that my PHI may be used to carry out treatment, payment, or healthcare operations.
I understand that I may revoke this authorization at any time by notifying Bakersfield Eye Care
Optometric Center in writing.
I have received a copy of Bakersfield Eye Care Optometric Center's Notice of Privacy Practices prior to
signing this consent.
I understand I have the right to restrict how my PHI is used or disclosed by notifying Bakersfield Eye
Care Optometric Center of my wishes in writing.