New Patient Paperwork

  • Check your preferred means of contact.
  • I understand that I am ultimately responsible for my bill and any fees associated with collecting unpaid balances. There will be a 30% processing fee plus court costs added to delinquent balances if sent to a collection agency. There will be a $20.00 charge for returned checks.
  • Effective Date of Notice: Jan 1, 2010 ACKNOWLEDGEMENT OF PRIVACY POLICY AND PRACTICES I understand that in an attempt to protect the privacy of my identifiable health information, Jessup Eye Care has established a Privacy Policy and guidelines for Privacy Practices within their office(s). This information details the use and/or disclosure of information contained in my personal medical/optometric records kept for the purpose of diagnosis, treatment, payment and health care operations. In accordance with HIPAA Regulations, a copy of the Jessup Eye Care Privacy Policy and Practices has been made available to me while in the office today. Should I choose to have a personal copy, one will be given to me at no charge.
  • Jessup Eye Care ∙ 7091 Old Harding Pike, Suite 105 ∙Nashville, TN 37221 IF YOU WOULD LIKE TO USE INSURANCE PLEASE READ AND COMPLETE THE FOLLOWING We are willing to act as your agent in obtaining maximum benefits from your insurance company. We will contact your insurance company and obtain benefit information which will be applied to your bill. Please be aware of the following:
    ● Not all insurance companies provide vision care.
    ● Vision care insurance covers eye exams and/or glasses and contact lenses.
    ● Major medical insurance covers eye problems (i.e. conjunctivitis), eye injuries and diseases (i.e. cataracts, glaucoma, etc.)
    ● Many times vision care insurance plans and major medical insurance plans are covered by different companies.
    ● We will submit claims for services provided to your insurance company, but you are ultimately responsible for the amounts that your insurance company does not cover.
    ● Depending on your plan or coverage, you may be instructed to pay at the time services are rendered and receive reimbursement from your insurance company.
  • Please fill out the following information so that we may obtain benefit information and submit your claim to your insurance carrier:
  • ● I authorize the use of this form on all insurance transactions.
    ● I authorize release of information to all my insurance carriers.
    ● I authorize my doctor to act as my agent in helping me obtain payment from my insurance carriers.
    ● I authorize payment directly to my doctor should he/she accept assignment for such.
    ● I understand that I am ultimately responsible for the portion of my bill that my insurance does not cover.
    ● I understand that I am responsible for my bill if my insurance doesn’t pay or respond to claims within 30 days.
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Contact Us

Phone: 615-662-2800
Fax: 615-662-0411
Cell: 615-513-0385

7091 Old Harding Pike, Suite 105
Nashville, TN 37221


Tue, Thu 8:00 am – 6:00 pm
Wed, Fri Noon – 6:00pm
Sat, 8:00 am – Noon

A Nashville Optometrist winner of the 2015 Patients’ Choice Awards.
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