Eyetopia
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Eyetopia Individual Membership Enrollment
1387 Sattler Road, Sattler, Texas 78132
Phone: 830-964-6444 | 800-662-8264 | Fax: 866-772-0285
www.Eyetopia.org
Secure enrollment
— your information is encrypted in transit (SSL/TLS).
Member Information
Agent
Agency
Member Name
Gender
Select
Male
Female
Date of Birth
Phone
Alternate Phone:
Email
SSN
Encrypted in transit
Main Address
City
State
Zip
Alt. Address
Coverage Type
Plan Type
Select Plan
Plan
Select Tier
Effective Date
Dependents
First
Middle
Last
Gender
DOB
Relationship
Alt. Address
Select
Male
Female
Select
Spouse
Child
Adult Other
Select
Male
Female
Select
Spouse
Child
Adult Other
Select
Male
Female
Select
Spouse
Child
Adult Other
Select
Male
Female
Select
Spouse
Child
Adult Other
Select
Male
Female
Select
Spouse
Child
Adult Other
Payment Options
Frequency
Select
Monthly
Quarterly
Yearly
Next withdrawal date:
(If left blank future withdrawals will occur based on today's date)
1. Credit/Debit Card
Card #
Card details are encrypted in transit
Exp. Date
CVV
Billing Address
Address
City, ST, Zip
2. E-Check
Account Type
Checking
Savings
Bank Name
Account #
Bank details are encrypted in transit
Confirm Account #
Routing #
Confirm Routing #
Authorization
I hereby apply for enrollment in an Eyetopia vision care Membership Plan and agree to participate for a minimum of one (1) year. I understand that canceling my Membership prior to the expiration date may make me ineligible for re-enrollment, and that I will be direct billed for the balance of any outstanding membership fees or the applicable usual and customary fees incurred for services rendered.
Signature
Date
Submit