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Co-payment Consent

  • MANHATTAN VISION ASSOCIATES
    160 East 56th Street, Suite 300
    New York, NY 10022
    212-688-4277

    I understand that I am responsible for any co-payments that are linked to my examination and/or glasses/contact lens benefit through my vision insurance

    I also understand that medical testing may be necessary and will be billed to my medical insurance (e.g. diagnostic imaging and testing for ocular disease such as glaucoma, cataracts, etc.) I understand that I am responsible for any co-payments, co-insurances, and/or yearly deductibles that are linked to my medical insurance.

    If I do not have separate vision insurance and my major medical does not cover the refraction for my glasses, I understand that I am responsible for payment for the refraction and will be billed accordingly

  • Date Format: MM slash DD slash YYYY