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Membership Enrollment Form

Two options are provided for submitting the Enrollment Form. You may complete it online and submit electronically. If you choose to use the print version, you can scan a completed copy and email to info@EyeAssure.net or you can fax to 402-476-6547.

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As a convenience to me, I hereby authorize EyeAssure, LLC to charge my account for payments for initiation fees and membership fees and agree to provide EyeAssure with necessary information to establish a monthly automatic bank withdrawal. EyeAssure, LLC will contact me for required information.

In the event I want to cancel this authorization, I will provide written notice to EyeAssure, LLC, with the understanding that cancellation will result in termination of membership. If the specified account does not have sufficient available funds on deposit on the day that EyeAssure, LLC attempts to deduct the payment, EyeAssure, LLC shall determine whether or not the deduction is attempted one or more additional times. Failure to complete monthly payments will result in termination of membership.

It is understood that the date of bank withdrawal transactions will be on around the first day of each month.  If membership registration and payment information is received by EyeAssure, LLC on or before the 15th day of the month, initial payment will be processed that month with subsequent payments beginning on or around the first day of the next month. If membership registration and payment information is received by EyeAssure, LLC after the 15th day of the month, initial payment will be processed on or around the first day of the next month. Provider is not entitled to benefits of membership in EyeAssure, LLC  until initial payment is processed.

I acknowledge that in order to qualify for continued enrollment as a member of EyeAssure, I will need to meet credentialing requirements as outlined in the Provider Manual and will  need to attest to the following within six (6) months of my enrollment:

  • I am currently using certified EHR software for patient records and claims
  • I am enrolled in AOA M.O.R.E. or a similarly-recognized health data registry
  • I regularly monitor and document diabetic retinopathy in patients and provide timely reports of findings to the patient’s primary care physician
  • I report any vision status that could put a patient at risk of falls to the patient’s primary care physician
  • I am not aware of any pending disciplinary actions or investigations as to the status of my optometric license

Send completed Membership Enrollment to EyeAssure (submit electronically below, by fax to 402-476-6547, or by email to info@EyeAssure.net). Signed Provider Agreement must also be returned to EyeAssure and initial membership payment must be complete before Provider is accepted as a member of EyeAssure.