For Patients

Patient Forms

To save time during your appointment, print out these forms, fill them out and bring them with you.

Registration Form		Patient History Questionnaire		Notice of Privacy Act

English	Spanish	English	Spanish	English

Patient Survey

English

Please note that these are PDFs. If you do not have Adobe Acrobat Reader on your computer, click here or on the logo at right to download the program and open these files.

Insurance Plan Participants

We want you to get all of the benefits you are eligible for from your health insurance coverage. Many health insurance plans require a referral from your primary care physician prior to consultation with a specialist. In addition, most plans also require preauthorization before any type of surgical procedure or laser treatment. It is your responsibility to obtain the required referral from your primary care physician. Failure to obtain a referral or preauthorization, if required, will result in your health insurance denying payment for our services. In this case, you will be held financially responsible for all services obtained through our office.

If you are uncertain whether your health insurance requires a referral or preauthorization, please call your health insurance’s customer service representative or your primary care physician’s office for more details. If you need assistance, please call our:

Billing Department at (718) 261-4120
Monday through Friday 9:00 am to 5:00 pm.

1199 National Benefit Fund
Advantage United Health Complete
Aetna/US Healthcare (HMO, PPO, POS)
Affinity
Amerihealth (Multiplan)
Atlantis
Beech Street
Blue Cross/Blue Shield (HMO, POS, PPO)
Centercare
Cigna (PPO, Open Access Plus)
Connecticare
Emblem Health CompreHealth
Emblem Health EPO
Empire Plan
Elder Plan
Evercare
Fidelis Medicare
First Health
GHI
Great West
Healthnet (PHS)
Health First
Health Plus

HIP
HIP-CMO
Horizon (Mulitplan Only)
Magnacare
Medicare Advantage Plan (VNS Choice Select)
Medicare-Empire
Medicare-GHI
MedNet/Galaxy Health Plan
Metroplus
Multiplan
Oxford (All Plans)
PerfectHealth
PHCS
Railroad Medicare
Select Pro
Storeworkers Security Plan
Transparent Health Network
Unicare
United Health Complete
US Family Health Plan
VNS Choice
Most Local Carriers

Please Note: We do not accept GHI HMO

Please call our Billing Department for more information if you do not see your insurance plan listed.

Billing Department - (718) 261-4120

Many health insurances require a co-payment. You are required to pay for any co-payments at the time of your visit. We will bill your health insurance directly for our services. After your health insurance has made payment, we will send you a bill for any applicable patient balances (i.e. deductibles).

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Method of Payment

Flexible Spending Plans

Many employers offer this as a health benefit. FSP, these plans are pre-tax contributions made directly from your paycheck and can be used for eligible healthcare-related expenses such as Laser Vision Correction. For more information on this type of plan check with your health insurance administrator.

Payment in Full

We accept cash, check, and all major credit cards.

CareCredit

CareCredit for vision

We’re pleased to offer our patients the CareCredit® card, North America's leading patient payment program. CareCredit lets you begin your procedure immediately — then pay for it over time with low monthly payments that fit easily into your monthly budget. Now you don’t have to save up for years to finally get the vision you’ve always wanted.

Like a credit card, but better

CareCredit cards work just like a regular credit card, but is exclusive for healthcare services. CareCredit offers low monthly payment plans for healthcare procedures not commonly covered by insurance, including LASIK.
Learn more by visiting CareCredit.com or contacting our office. Ready to apply?

Apply online for your CareCredit card today.

For any questions/comments please click here to contact us.

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