Vision Exam Request Form

Vision Exam Request Form
Today's Date*

MonthDayYear
Date
Service type requested:*

Vision ExamGlasses (must have current prescription)
Patient Information
Name of Patient:*

First NameLast Name
Patient's date of birth:*

MonthDayYear
Date
Is the patient a minor (under 18) or a dependent over 18?*

YesNo
Parent/Guardian Name (if patient is a minor or dependent):

First NameLast Name
Contact Information
Phone Number (Patient or Parent)*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Information
Please consult with your insurance to verify your eligibility and benefits for services.
Primary Medical Insurance (Name of company):*
Policy (ID) Number:*
Group Number:*
Who is the policy holder? (does not apply to MA plans)*

SelfSpouse/Partner
If applicable, name of policy holder:

First NameLast Name
If applicable, DOB of policy holder:

MonthDayYear
Date
Front of Medical Insurance Card:
Back of Medical Insurance Card:
State Issued Photo ID (Front Only):
Signature*

Clear
Supplemental Vision Insurance

(IF APPLICABLE)
Some commercial (non-medical assistance) health plans offer supplemental vision plans. A Chance To Grow accepts a limited number of these plans. If you have a vision plan, please provide details below. Supplimental Insurance typically covers limited amounts. Please contact your insurance company to verify your eligibility and benefits for services. I understand by sharing this information, I am responsible to seek out what coverage my plan(s) provides.
Vision Insurance Company Name:
Policy (ID) Number:
Group Number (if applicable):
Front of Vision Insurance Card:
Back of Vision Insurance Card:
Thank you for you interest in ACTG Vision! Please note the Vision Clinic is open a few days per month by appointment Response times to requests may vary - please allow up to 5 business days for a response.
Should be Empty:

Vision Exam Request Form

Patient Information

Contact Information

Insurance Information

Supplemental Vision Insurance