ACQUIRED BRAIN INJURY :Patient History

The Vision Development Team extends the courtesy of filling out a medical insurance claim form for you to submit to your insurance company for reimbursement to you.
I understand that I will be required to pay for services at the time rendered.
I authorize Alexandar Andrich, OD, FCOVD to release any information required by my insurance company.
I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

(Guardian signature required if patient is under 18)

Please silence cell phones prior to entering the Doctor’s exam room Thank you!