At Friedrichs Family Eye Center, PC, we value your time. In an effort to save you time in our office, you can download and complete our
patient form(s) prior to your appointment.
- You will need AdobeReader® to download and complete the forms. Click here to download.
- Download the required form(s). Print out the form(s) and complete the required information.
- Fax your printed and completed form(s) to our office or bring them with you to your appointment.
Online Registration Form
Please be prepared to sign this document upon arrival at the office. Thank you.
INSURANCE: Please present your insurance ID at each visit, it is the responsibility of the patient to make accurate
and detailed insurance information available to us to enable processing of his or her insurance claim. The patient is
to be considered self-pay until this information is provided to us.
All co-payments and non-covered services are due at the time of service. Self-pay patients are responsible for payment in full at the time of services.
REFERRALS/AUTHORIZATIONS: It is the responsibility of the patient to obtain a referral from his or her primary
physician prior to the scheduled visit if a referral is required. If a referral is not obtained, the patient accepts full
financial responsibility for all services rendered.
Insurance Authorization for Assignment of Benefits – I hereby authorize and direct payment of medical benefits to Friedrichs Family Eye Center on my behalf for any services furnished to me by its providers.
Vision and Medical Coverage - There are two types of insurance benefits that will pay for services and products. You may have both and our practice may accept both. Vision care plans only cover well visits, may have a co-pay and allow discounts on materials. They DO NOT cover diagnosis, management or treatment of eye disease, eye allergies or eye injuries. In the event that you have any eye health problems or a systemic health problem that has ocular (eye) complications, your medical insurance will be utilized for the services provided.
Authorization to Release Records – I hereby authorize Friedrichs Family Eye Center to release to my insurer,
governmental agencies, or any other entity financially responsible for my medical care, all information, including
diagnosis and the records for any treatment or examination rendered to me needed to substantiate payment for such
medical services as well as information required for precertification, authorization or referral to other medical provider.
I acknowledge that I was offered a copy of the Notice of Privacy Practices for this office.