Insurance Forms | PersonalEyes Vision Care in Grand Rapids

Payment Options

At PersonalEYES Vision Care, we understand that our clients have different payment needs and preferences. That's why we offer a wide range of payment options to ensure that we can provide the best possible service. We accept the following payment methods:

Vision Plans

We participate with VSP and EyeMed for vision exams and materials (glasses/contact lenses). If your visit is for other conditions (cataracts, glaucoma, dry eye or diabetes, etc.) then it will be covered by medical insurance. We also accept HSA or FSA funds for eye exams, glasses, contacts, sunglasses and more.

Medical Insurance

We accept most of the major medical plans in the Grand Rapids area including Medicare, Medicaid, Priority Health, BC/BS, Aetna, Cigna and Humana. Please contact us if you’d like us to verify benefits or have any questions. You don’t need separate “eye insurance” for exams relating to any medical concerns of the eyes.

Patient Forms

Receipt of HIPAA Documents

This is a required form that verifies that the HIPAA Notice of Privacy Practices has been presented and that the patient (or personal representative) understands the information contained therein. The acknowledgment form ensures that the patient (or personal representative) understands this information and gives their consent for the disclosure of their personal health information.

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Patient History Form

This form allows you to fill out your personal information prior to your appointment. This is necessary in order to enter your information correctly into our computer system. It also helps us confirm and bill your insurance. In addition, the form provides our doctors with personal and medical history that is essential for multiple aspects of your visit. By taking the time to fill out this form in advance, you can help make sure that your visit to PersonalEyes Vision Care is as smooth and efficient as possible.

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Records Release / Request Form

Please fill out this form if you need your records transferred from another doctor to our office, or if you’re requesting us to send your records elsewhere.

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