Brems Eye Center

300 E. Osborn Road         9746 N. 90th Place, Suite 101
Phoenix, AZ 85012            Scottsdale, AZ 85258         
(602) 200-0770                  (480) 391-0020             

General Insurance Waiver

Some insurance companies will only pay for services which they deem reasonable and medically necessary. If your insurance company determines that a particular service, although it would be otherwise covered, is not reasonable or medically necessary, it will deny payment for that service. Examples of some of the services that may be denied are refractions, a balance left that went toward your deductible, or any procedure done for routine or cosmetic reasons. There is a possibility that other procedures may be denied. Reasons for denial maybe "non-allowed" or "non-covered" services. Routine eye exams that show no medical problems may not be covered by medical insurance.

Please read and sign the following statement:

"I have been informed by my physician/supplier of some of the procedures and reasons why it may be denied payment from my insurance company. If my insurance company denies payment, I agree to be personally and fully responsible for the payment."

 

Name:________________________________________________

Signature:__________________________________Date:_______