To submit an on-line medical history form, please open this link   If you need to list more than 4 medications, you may want to bring a medication list with you to your exam.  This form is for EVERYONE, not just first time patients.  Completing this form will speed up the check in process.  Thank you.

Do NOT use these symbols on your form:  #,*,<,~.  Thank you.

• Please provide us with your current vision and medical insurance information. We ask that you provide your vision  insurance card at each appointment. Vision Service Plan usually does not have a card.  (You can print your own at www.vsp.com)  You will need to provide the member’s social security or identification number.
• Please provide your current major medical card.
• You may be asked for a photo ID.
• Please check your vision benefits before your scheduled exam date.  It is your responsibility to know your insurance plan.  Your insurance card should have a phone number or website listed-sometimes on the back –to find out about your benefits.   REMEMBER that (a.) Vision and Medical benefits may not be with the same company and (b.) obtaining benefit information does not guarantee payment.
•  We routinely authorize VSP benefits about 4 days prior to your exam and notify you if the exam benefit does not coincide with your scheduled exam date or if you are not currently a member of VSP.

• We bill many types of insurance as a courtesy to our patients. Your insurance plan may deny payment for services or products even after the services have been completed. You are ultimately responsible for all fees relating to your care.

• We do NOT routinely submit co pays to secondary insurance. Determination of submitting fees to any secondary insurance will be on an individual basis.   Minnesota has stringent laws about electronic claims which many other states do not yet comply with making it nearly impossible to file.

• Payment for eyeglasses and contact lenses is due prior to placing the order.    We accept several methods of payment including cash, check, or credit cards.

• You will be asked to sign an assignment of benefits form which allows us to bill your insurance company and receive payment from them for your visit. If benefits are assigned to you, we can submit your claim, however, you are responsible for paying for your services on the date of service.

• If at any time you have questions regarding any fees or services, please discuss them with us promptly and frankly. We will make every effort to avoid a misunderstanding.