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Serving Spring, The Woodlands & Tomball

Located on FM 2920, 1/2 mile west of Kuykendahl

Call 281-374-4354
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Home » Patient Forms » Assignment of Benefits

Assignment of Benefits

  • 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

  • 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
  • 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

  • Date Format: MM slash DD slash YYYY