CALL 1-888-524-5232
FOR MORE INFORMATION.
Full Name:
And, if applicable, the Primary Member
Home Address:
City:
State:
Zip:
Main Phone:
Other Phone:
Email:
Date of Birth:
and, if applicable the Primary Member date of birth
Insurance
Company:
Insurance Co.
Phone Number:
Your ID#
INSURANCE COMPANIES
MOST INSURANCE COMPANIES WILL PAY A PORTION OR ALL OF THE FEE DEPENDING ON YOUR COVERAGE. IF YOU WOULD LIKE US TO CHECK WITH YOUR INSURANCE COMPANY FOR YOUR BENEFIT/ELIGIBILITY FOR A PROSTHESIS AND REQUEST A PREAUTHORIZATION, PLEASE FILL OUT THE FORM ON THE OPPOSITE SIDE.
ALSO, PROVIDE US WITH AN ALTERNATIVE PHONE NUMBER TO REACH YOU, IF WE HAVE ANY ADDITIONAL QUESTIONS, OR TO GET IN TOUCH WITH YOU ONCE WE RECEIVE APPROVAL.
OUR DIRECT NUMBER IS
1-888-524-5232
OUR EMAIL ADDRESS
INFO@OPHPROS.COM
MAIN OFFICE:
OPHTHALMIC PROTHESTICS, INC.
5005 CAROLINE ST.
HOUSTON TEXAS 77004
OFFICE 713-524-5232
FAX: 713-524-6744
TOLL FREE 1-888-524-5232
Covered by Most Insurances and Medicare! Pre-Authorization Available Call 1-888-524-5232 for more information.
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