First Eye Care
Phil Stiles, O.D.
2810 E. Trinity Mills Rd #173
Alan Weissman, O.D.
Carrollton TX 75006
Chris Peterson, O.D.
972-416-1270
Melinda Surdacki, O.D.

INSURANCE FORM

Patient First Name:
Patient Last Name:
Patient's Date of Birth: mm/dd/year

Please bring your Medical Insurance Card with you to your appointment. Oftentimes, we need the
Major Medical insurance information to verify your vision coverage.

VISION INSURANCE

Name of Vision Insurance Plan:
  If OTHER, please enter insurance plan here:
Patient is:
   
PRIMARY MEMBER'S NAME:
  Primary Member's Date of Birth: mm/dd/year
  Member ID Number:
  Primary's last 4 digits of SSN:

MEDICAL INSURANCE

Name of Medical Insurance:
  If OTHER, please enter here:
Patient is:
   
PRIMARY MEMBER'S NAME:
  Primary Member's Date of Birth: mm/dd/year
  Member ID Number:
  Group Number:
Phone number for providers to call and verify benefits and eligibility: