Name: Little Lake Family Eye Care
Address: 11 Lakeside Terrace #102, Barrie, ON, L4M 0H9, CA
Telephone: 705-503-3937

OHIP Fee Consent Form

OHIP covers the basic elements of an eye examination. Little Lake Family Eye Care uses advance diagnostic testing not covered by OHIP to detect and manage eye disease earlier and more precisely, resulting in better health outcomes.

Benefit and Consent Assignment Form

I hereby assign benefits payable for the eligible claims to Little Lake Family Eye Care, who is responsible for submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to Little Lake Family Eye Care. In the event my claim( s) are declined by the insurer/plan administrator, I understand that I remain responsible for payment to Little Lake Family Eye Care for any services rendered and/ or supplies provided. I acknowledge and agree that the insurer/plan administrator is under no obligation t o accept this Assignment, that any benefit payment made in accordance with this Assignment will discharge the insurer/plan administrator of its obligations with respect to that benefit payment, and that in the event the benefit payment is made to me, the i nsurer/plan administrator will also be discharged of its obligation with respect to that benefit payment. I understand that this Assignment will apply to all eligible claims submitted electronically by Little Lake Family Eye Care and that I may revoke it at any time by providing written notice to the insurer/plan administrator. If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to Little Lake Family Eye Care.*
- I hereby consent to the above
Name*
First Last
Date*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Policy Holder's Name*
First Last
Policy Holder's Date of Birth*
MM slash DD slash YYYY
Relationship to the Policy Holder*
- Self
- Spouse
- Child
Insurance Name*
Policy Number*
Member ID*
Signature*

Forms

OHIP Fee Consent Form

Patient Registration Form

Patient Information

Personal Information

Eye History

Dry Eye Questionnaire

1. Questions about EYE DISCOMFORT

2. Questions about EYE DRYNESS

3. Question about WATERY EYES

Glasses History

Contact Lens History

Medical History

Privacy Policy

Benefit and Consent Assignment Form

Little Lake Family Eye Care

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