Patient Registration Form

Koury Family Eye Care provides both Routine eye examination services and Medical (health) eye care. When applicable, Koury Family Eye Care will bill in-network Vision Plans (Davis Vision, EyeMed, etc.) for routine eye examinations. However, if a medical eye condition (ie. glaucoma, eye injury, infection, diabetes, or other condition) requires evaluation, testing, or treatment, Koury Family Eye Care must bill your Medical Insurance in accordance with insurance contractual agreements.

You may not be using Insurance Benefits for this appointment but please understand and acknowledge our policy. The following statements are applicable if the patient is utilizing insurance benefits, whether today or in the future. I authorize release of any medical information and medical records to my insurance company necessary to process a claim. I authorize payment of benefits to be made directly to Koury Family Eye Care, LLC for services rendered to me. I authorize use of this form on all of my insurance submissions and permit a copy of this authorization to be used in place of the original. I understand that I am fully responsible for payment of any Co-Insurance, Co-Payments, Deductibles, and any other charges that are incurred that are not covered by my insurance. I understand this office does not in any way guarantee payment for my exam by accepting my insurance plan.