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Patient Consent Form

  • DR. ARKADY SELENOW – DR. STEVEN ALI
    160 EAST 56TH STREET – FLOOR 7
    NEW YORK, NY 10022
    TEL. (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

    The staff of MVA will explain your insurance coverage to the fullest extent possible. The information we are given as providers from your major medical insurance is not a guarantee. Ultimately, it is the responsibility of each patient to know the details of his insurance policy.
  • Date Format: MM slash DD slash YYYY