New Patient Form

Name: *

First Name Middle Name Last Name

Birth Date *

Month Day Year

Sex:

Male Female

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Cell Phone Number: *

Area Code Phone Number

Allow Text? Y/N *

E-mail: *

Primary Care Physician: *

(Eye Health) Do you have any of the following? Please list or type none. *

Vision change
Floaters
Flashes
Red Eye
Dry Eye
Watery Eye
Burning
Soreness
Sandy/Gritty
Mucus Discharge
Eye Pain
Foreign Body Sensation
Sty or Chalazion
Light Sensitivity
Droopy Lids
Double Vision
Glaucoma
Macular Degeneration
Retinal Detachment

(Medical History) Do you have any of the following? Please list or type none. *

Allergies
Asthma
Headaches
Arthritis
MS
Thyroid
Diabetes
Lupus
High Blood Pressure
Heart Problems
Kidney Disease
Weight Loss or Gain
Cancer
Other

List all medications you are current taking or type none. *

Are you allergic to any medications? If yes, please list. Y/N *

Are you a smoker? *

Do you drink alcohol? *

We accept the following insurance plans: Aetna, Blue Cross Blue Shield, Blue Med, Community Eye Care, Eye Med, Health Team Advantage, Medicare, Medicare Complete, UMR, and VSP. Please list your insurance provider. If your plan is not listed, we may be out of network and charges will be patient responsiblity.

What is the name of your insurance? Please bring your medical insurance card with you at your appointment. (Not necessary for vision plans.) *

Name of Policy Holder if not patient:

First Name Last Name

Birth Date of Policy Holder:

Month Day Year

Release of information: List names of authorized family members to release patient information.

FEES and SERVICES: Good Faith Estimate Some fees are not covered by your insurance. Please be advised these fees are patient responsibility. Those include Optos imaging and refraction vision check. Those tests are performed on every complete eye exam regardless of medical or routine vision coverage. New patient exam $204/ Existing patient exam $153/ Refraction vision check $35/ Optos photo imaging $29/ Photos $85/ Visual Field $85/ OCT $85/ Pachymetry 76514 $36/ Gonioscopy 92020 $50/ Epilation 67820 $60/ Contact lens annual exams $87-$125/ Specialty Contact Lens Fitting $400-$850 __________________________________________________________________ Advance Beneficiary Notice ABN: If you are scheduled for special tests please note, insurance companies may not pay for certain tests and materials. Photos $85/ Visual Field $85/ OCT $85/ Refraction $35 . __________________________________________________________________ If my insurance company denies payment, I understand that I am responsible for non-covered services. Ask your assistant for fee information before you are tested if you are concerned your insurance may not pay. *

First Name Last Name

Disclaimer
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or
special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them toupdate the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. To learn more and get a form to start the process, go to www.cms.gov/nosurprises/consumers or call 1-800-985-3059. For questions or more information about your right to a Good Faith Estimateor the dispute process, visit www.cms.gov/nosurprises/consumers or call
1-800-985-3059.

Office Policies: Payment and Fees: Payment is expected at time of service for fees not allowable by your insurance carrier. Insurance companies do not guarantee payment. Any additional balance will be billed to your account. We do not file secondary insurance. Assignment of Benefits: I hereby assign all medical and/or vision benefits, to which I am entitled, from my insurance plan to Miller Vision Specialties. Authorization to Release Information: I authorize Miller Vision Specialties to release all information pertaining to patient treatment to his/her insurance companies and to any other physician or health care provider to whom the undersigned may be referred. Consent to Treat: I authorize medical treatment of myself/minor by the physicians of Miller Vision Specialties. Prescription Release: Notice of prescription release requirement of contact and glasses for complete eye exams and contact lens fittings. Prescription received. Notice of Privacy Practices: I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can be used to: *Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. *Obtain payment from third party payers. *Conduct normal healthcare operations such as quality assessments and physician certifications. A copy of the Notice of Privacy Practices containing a more complete description is available within the office. I understand this office has the right to change the Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy. SIGNATURE REQUIRED SIGN WITH MOUSE (DESKTOP) AND FINGER(CELL) *

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