authorization-of-payment-form

Date of Birth (required)

MEDICAL INSURANCE INFORMATION (required)
Please note that we accept PPO or Medicare coverage. We do not accept any HMO or Medicare Advantage (Medicare HMO) plans. If you would like to be seen on a private pay basis we would be happy to accommodate you! Please see information below on this form. Please indicate your current insurance carrier below (check one):

MEDICAL INSURANCE ID#
please provide the ID number for your PPO or Medicare plan

Authorization of Payment (required)
I am aware that the initial personalized dry eye consultation with Dr. Austin will be submitted to my medical insurance carrier if I have insurance that is accepted by Dr. Austin's office (PPO or Medicare plans). I understand that Dr. Austin's office does not accept HMO or Medicare HMO (Medicare Advantage plans) and that if this consultation is not covered by medical insurance I will be seen as a private pay patient and be charged for the initial dry eye consult. If it is determined that you are a candidate for an in office procedure that is not covered by your medical insurance you will be responsible for payment at the date of your treatment. We are available to discuss payment or financing arrangements (CareCredit) for these procedures at the time of your consult.