15 & Under Welcome Forms for Soonercare Patients

15 & Under Welcome Forms for Soonercare Patients


    Thank you for choosing our office for your eyecare needs. We’re glad to help if you have questions

    All Patient Information is Confidential

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  • Insurance Information

    If you are using insurance, we need to copy your medical and vision cards.
    We treat both medical eye problems as well as vision care. Thank you.

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  • Your Eye Health and Vision are important to us

  • Health History

    Please indicate if you or your family (blood relatives only) have any of the following


  • Payment Information
    I authorize you to bill my insurance for any applicable services or products, and I understand
    that payments for non-insured services are due the same day services are rendered
  • Clear Signature

  • Notice of Privacy Practice
    Methods of Payments

    No Insurance?

    No problem. Harrel Eyecare offers a discount for all non-insurance patients for their Vision or
    Medical exam. We also, accept all major credit cards, Care Credit, cash or checks

    Vision Plans

    Some vision insurance plans do not provide an insurance card. Vision plans usually include
    benefits towards glasses or contacts. (Examples: VSP, EyeMed, Avesis, Superior Vision, etc.).
    Medical insurances generally do not cover these benefits. Medicaid (Soonercare) only allows
    glasses for patients less than 20 years of age and they do not cover contact lenses.

    Medical Insurance

    Refractions (checking vision) & the contact lens portion of the exam are not generally covered
    by medical plans. We can file your insurance on your behalf, but this does not guarantee
    payment and any balance will be paid by you. If your deductible has not been met for the year,
    you will be responsible for services rendered. We keep medical insurance information on file
    because we perform medical eye care. We use medical insurance for infections, foreign body
    removals, eye disease, treatments, etc.

    We are glad to answer any questions regarding your insurance benefits. Thanks!

    Please Sign Here – Privacy Practices

    I acknowledge that I have read or have had the opportunity to read the Notice of Privacy
    Practices (available at the front desk).

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  • Clear Signature

  • Monte Harrel O.D., F.C.O.V.D. Tiffany Harrel, O.D. Savanah Sayler, O.D.
    4520 S. Harvard Ste. 135 Tulsa, OK 74135 pho: 918-745-9662 fax: 918-392-7006

    Please check any that apply to help us know how to provide the best care for your

    Developmental Checklist

  • “SoonerCare will provide for payment of lenses and frames for
    children only. This Coverage includes one set of lenses and frames
    per service year.”

    -Garth L Splinter, M.D., M.B.A
    State Medicaid Director

    We offer a one year warranty on all of our frames; one replacement frame may
    be obtained within one year of the exam date. Pieces of broken frame are
    required for any replacement; loss and theft are not covered by this warranty.
    Lenses are covered under a one year Scratch Warranty. Damaged lenses are
    required for replacement, and may only be obtained once within the year of exam
    This warranty is courtesy of Harrel Eye Care Center and is not affiliated in
    any way to your SoonerCare Coverage.

    If frame or lenses have been replaced under warranty or a replacement is
    needed due to loss or theft, the prices are as follows:

       $74.00 frame only
       $68.00 lenses only
      $99.00 frame and lens package price

  • “The replacement of or additional lenses and frames are allowed [to
    be billed to SoonerCare] only when medically necessary [as
    prescribed by doctor]… The replacement of lenses and frames due to
    abuse and neglect by the member is not covered.”

    -OAC 317:30-5-432.1

    If you have any questions, please call your SoonerCare Case Worker.
    If you would like to see a copy of the clarification letter in accordance with
    OAC 317:305-432.1 please ask an associate.

    I acknowledge that I have read and understand the above Advisement and
    consent to the contents.

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  • Clear Signature