If you are a member of the above Insurance plans, your insurance company will be billed directly for services/ materials less
any applicable deductions (Copays, Co-insurance, etc.). Please provide your ID cards to the reception desk. If you
have other medical / vision insurance we will be happy to assist you in submitting a claim on your behalf for reimbursement to you.
1. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and not a
substitute for payment. It is the responsibility of the patient (or parent if minor) to pay any deductible amount, coinsurance,
or any balance not paid by your insurance
2. Payment is expected at time of service, unless other arrangements have been made in advance. In cases of Divorce, the
parent/Guardian present with the child will be responsible for payment.
3. In the event Dr. Todd Cohan, O.D. are not participating providers in your health plan you will be expected to pay for all services
and materials received.
4. I request that payment of authorized Medicare and/or insurance benefits be made on my behalf for any services furnished
me. I authorize any holder of medical information to release to the Health Care Financing Administration, its agents, or
any insurance carrier I may have, any information needed to determine these benefits or the benefits payable for
5. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered
as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance.
I hereby authorize said assignee to release all information necessary to secure the payment