Healthcare VSP Term

HEALTHCARE VSP TERM

Patient Information

Insurance / VSP Plan Information

Plan Effective Date:    Member Relationship to Subscriber:

Medical & Vision History

Do you currently wear corrective lenses? Glasses Contacts

VSP Terms, Authorizations and Acknowledgments

By signing below, Patient Name: acknowledges that the provider will submit claims to the named vision plan for covered services under the terms of the vision plan. Patient authorizes assignment of benefits to the provider and authorizes release of medical and vision records necessary to adjudicate claims.

Assignment of Benefits: I assign my VSP benefits and payment to the treating provider for covered vision services. I understand that any amount not paid by the plan, including copayments, deductible, or non-covered services, is my responsibility.

Authorization to Release Information: I authorize the release of pertinent medical, vision and billing information to my vision plan and other health care providers for purposes of treatment, payment and health care operations related to my vision care.

Financial Responsibility: I agree to pay all patient-responsible amounts at the time of service or as invoiced, including copayments, non-covered items, upgrade charges, and services rendered that exceed plan allowances. I understand that submission of claims to the plan does not relieve me of payment responsibility.

Term and Termination: This authorization and assignment remains in effect until revoked in writing. Revocation does not affect actions taken prior to receipt of written revocation. The provider may suspend or terminate care for failure to comply with payment terms or plan requirements.

Acknowledgment of Plan Limitations and Benefits: I acknowledge that plan benefit determinations, coverage limits and medical necessity are determined by my vision plan. The provider has explained the scope of services to be provided. I understand benefits may change and I am responsible for charges not covered.

HIPAA Privacy Acknowledgment: I have received or been offered the provider’s Notice of Privacy Practices and understand how my protected health information may be used or disclosed.

Dispute Resolution and Governing Law: Any dispute arising under this VSP Term shall be governed by the laws of the state where services are rendered. Parties agree to good faith negotiation; if unresolved, disputes may be submitted to binding arbitration in accordance with applicable arbitration rules, subject to the provider’s written policies.

Authorization Expiration Date: This authorization will expire on unless earlier revoked in writing.

Patient Responsibilities & Certification

I certify that the information provided on this form is accurate and complete to the best of my knowledge. I understand the scope and limitations of my vision plan benefits, and I accept financial responsibility for services rendered that are not paid by my plan. I understand I may revoke any authorization in writing, subject to prior actions taken in reliance on the authorization.

Sign Now