OUR GOAL AT THE EYE INSTITUTE FOR MEDICINE & SURGERY IS TO ENSURE THAT YOUR VISIT IS AS CONVENIENT AND PLEASANT AS POSSIBLE. PLEASE TAKE THE TIME TO COMPLETE THIS ONLINE FORM AT LEAST 2 BUSINESS DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.
PLEASE PROVIDE MEDICATION INFORMATION BY FILLING OUT THE TABLE BELOW OR UPLOADING A PICTURE/FILE. IN ORDER TO BEST SERVE YOU, THE EYE INSTITUTE ASKS THAT YOU PROVIDE UPDATED AND COMPLETE INFORMATION.
LIFETIME MEDICARE PART B SIGNATURE AUTHORIZATION: For services beginning today, I authorize any holder of medical or other information about me to release information to the Social Security Administration, the Center for Medicare & Medicaid Services or its intermediaries or carriers, to any other insurance or third party entity, or to Florida Eye Consultants, Inc., d/b/a The Eye Institute for Medicine & Surgery any information needed to obtain payment. I permit a copy of this authorization to be used in place of the original, and request payment of benefits be made to Florida Eye Consultants, Inc., d/b/a The Eye Institute for Medicine & Surgery.
MEDIGAP AUTHORIZATION: I request that payment for Medigap Benefits be made on my behalf to Florida Eye Consultants, Inc., d/b/a The Eye Institute for Medicine & Surgery for services rendered. I understand that I must provide my supplemental/Medigap insurance policy information as there is no guarantee that claims information will automatically be forwarded to my supplemental insurance by Medicare. I understand that if my supplemental insurance does not make payment for my copayments, deductibles, or other charges, that I, the patient, am personally responsible for making payment in full to Florida Eye Consultants, Inc., d/b/a The Eye Institute for Medicine & Surgery.
INSURANCE AUTHORIZATION: I assign the benefits payable for services to Florida Eye Consultants, Inc., d/b/a The Eye Institute for Medicine & Surgery, and hereby authorize Florida Eye Consultants, Inc., d/b/a The Eye Institute for Medicine & Surgery to submit claims to my health insurance carriers as needed in order that payment be made for the services I have received. I authorize any holder of medical or other information about me to release said information to my insurance carrier, including any information about or related to submitted claims.
I authorize Florida Eye Consultants, Inc., d/b/a The Eye Institute for Medicine & Surgery to initiate a complaint to the Insurance Commissioner for any reason on my behalf. A photocopy of this authorization shall be used in lieu of the original. This authorization shall remain in force until revoked by me in writing. If my insurance carrier prohibits direct payment to the doctor, to the Practice, or to the Surgery Center, I hereby instruct and direct my insurance carrier to make the check payable to me and to mail it to The Eye Institute 1995 W. NASA Blvd Melbourne, Florida 32904.
I hereby instruct to Florida Eye Consultants, Inc., d/b/a The Eye Institute for Medicine & Surgery to deposit said check(s) into the account on my behalf as payment on my account for the services provided to me.
SELF PAY PATIENTS/PATIENTS WITH INSURANCE WITH WHICH WE DO NOT PARTICIPATE: I have been advised that payment is due on the day of service. I understand and agree that (regardless of my insurance status), I am personally responsible for any balance on my account. I have read all the information on this form and have completed the above questions. I certify that this information is true and correct to the best of my knowledge. I will notify The Eye Institute of any changes in insurance, address, telephone number or marital status in a timely manner.
MEDICATIONS: I acknowledge that the medication information provided is accurate and complete.
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