Prefer paper? You can print out our registration form and bring it in with you on the day of your visit. Click here for a printable form.
Required fields are in orange
We do not directly bill any other insurance. Insurance coverage and verification of coverage for reimbursement is the sole responsibility of the patient. Professional fees are non-refundable.
I hereby authorize THE OPTIK to release any medical or other information necessary in order to process insurance claims billed on my behalf. I also authorize payment directly to the doctor for any benefits available under my insurance plan. I understand that I am financially responsible for any fees that the insurance companies do no pay including co-payments, deductibles and non-covered services. Our office does not accept responsibility for collecting or negotiating disputed insurance claims past 60 days. Regardless of your coverage you are responsible for all incurred charges. Non- participating plans may reimburse you directly. A standard billing service charge of $2.00 will be posted on all accounts 30 days or older. A bank service fee of $40 will be charged on any checks returned for insufficient funds. Accounts 90 days old will be submitted to a collection agency.
Note to all contact lens patients- contact lens exams, fittings, classes, and evaluations are not covered benefit under MOST insurance plans. If you chose to be examined for contacts and/or need to be fit with contact lenses, you will be responsible for the professional services due on the day of your exam. ALL contact lens exams and follow ups must be completed within 60 days of initial exam. Monitoring your eye health is the doctor's responsibility, therefore a ONE year expiration for the contact lens prescription may be deemed medically necessary to prevent eye damage and encourage correct contact lens compliance.
By pressing submit, you agree with the statement above and confirm that all of the information above is correct.
17423 139th Ave NEWoodinville, WA 98072
Phone: (425) 485-2600
Fax: (425) 485-2526