Farallon Eye Physicians (Susan Longar)

$Farallon Eye Physicians (Susan Longar) - Refraction$

Refraction & Insurance
Do you want a refraction today? (This is the test to get a glasses prescription. It's also needed as a starting point for contact lens prescription.)*

YesNoI'm not sure. Please help decide if I should have a refraction.
Insurance coverage for refraction (Vision insurance covers refraction. We accept the following vision insurances. Do you have one of these?)*

VSPMESEyeMed- Through Brand New DayHealth Plan of San Mateo Medi-CalHealth Plan of San Mateo Care AdvantageMedi-Cal - Secondary to MedicareI do not have coverage under one of the above. (We can bill your medical insurance for the refraction. If it's not covered, we will bill you for it. Our charge for the refraction is $65.00) Also, Medicare does not cover refraction. Many other medical insurances don't cover a refraction either.
Insurance Information
Name of Subscriber*

First NameLast Name
ID Number
Last four digits of SSN
Relationship to Subscriber

SelfSpouseParentOther
If we use your vision insurance today:

Vision insurance often does not cover medical diagnosis. If your doctor addresses a medical diagnosis, your medical insurance might be billed for a portion of today's office visit. Your insurane plans will determine if you are responsible for any costs, and we will bill you for them.
Patient Name*

First NameLast Name
Patient Signature*
DateTime
Should be Empty:

Refraction & Insurance