Full payment is due at the time of service.
WE ACCEPT MEDICAL INSURANCE AND MOST VISION INSURANCE
Vision insurance- ONLY covers routine vision exams and can give a material allowance for eyewear and
contact lenses. ItDOES NOT COVER the DIAGNOSIS/TREATEMENT or MANAGEMENT OF EYE DISEASES or
any EYE HEALTH PROBLEMS.
Medical Insurancewill be billed if you have any medical health problems with ocular complications, or any
eye health problem.
All eyewear and contact lenses deemed patient responsibility must be paid in full prior to ordering.
I hereby authorize Excel Eyecare OD PA to apply for benefits on my behalf for covered services rendered
by them. I also assign my benefits and request my payments be made directly to them. I agree to
assume responsibility for full payment pending any remaining balance that is not covered.