Pediatric Eye Exam Coverage Verification Form
Submit this form to verify insurance coverage for a pediatric eye exam. Please provide all required information accurately.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Subscriber/Guardian
*
Please Select
Self
Child
Stepchild
Other
Subscriber/Guardian Full Name
*
First Name
Last Name
Insurance Company Name
*
Insurance Member ID
*
Provider or Clinic Name
*
Date of Scheduled Exam
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Coverage Status
*
Coverage Verified
Coverage Not Verified
Pre-authorization Required
Additional Notes or Instructions
Submit Verification
Should be Empty: