Assignment of Benefits

Phone: <a class="ecp-phone-call-phone" href="tel:281-374-4354" style="text-decoration:none"> 281-374-4354
Fax: 281-320-2012
Email: admin@springkleinvision.com (Do not send personal health information by email.)

Name: springkleinECP2016
Address: 6603 FM 2920 Rd, Spring, TX, 77379, US
Telephone: +1 281-374-4354
Price range: $000 - $300

This form is consent from the patient or guardian to allow Spring Klein Vision Center to file benefits on your behalf. Please note that some services rendered may not be covered by your insurance provider.

I agree that I have been informed that the Optomap is NOT covered by any insurance at this time
Signature
This form is consent from the patient or guardian to allow Spring Klein Vision Center to file benefits on your behalf. Please note that some services rendered may not be covered by your insurance provider.

I agree that I have been informed that the Optomap is NOT covered by any insurance at this time
Signature
Signature
I here by authorize Spring Klein Vision Center to file my vision and /or medical benefits on my behalf, and there fore, I authorize my insurance carrier to direct payment of benefits to

Spring Klein Vision Center

6603 FM 2920

Spring, TX 77379
I agree to assume responsibility for full payment pending any remaining balance that is not covered by my Insurance Carrier.

If you have additional questions that we were unable to answer please refer back to your Insurance Carrier or your benefit packet
Print Patient's Name
Patient/Guardian Signature
Date

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