Privacy Practice Acknowledgement
I have received the Notice of Privacy Practices and have been provided an opportunity to review it.
Patient Waiver/Billing Policy
Because patients often have both medical and vision insurance, it is important to understand teh differences. Vision insurance does not cover medical eye problems, just as most medical insurances do not cover routine vision problems.
Vision Insurance Covers routine eye examinations only Helps pay for glasses or contact lenses
Medical Insurance Covers exams where any medical condition that can affect the eyes is evaluated. Examples of these conditions includes but not limited to the following: Diabetes High Blood Pressure Taking high risk medications Eye Diseases Cataracts Infections Dry Eye Allergies Lazy Eye Crossed Eye Glaucoma Abrasion
After your examination, the doctor will determine to which insurance the exam will be filed. Glasses and/or contact lenses might still be filed to your vision insurance if the exam is filed to your medical insurance. We try to be a provider on all major carriers. If we are a provider for your insurance we will file a claim to your primary insurance carrier. However, in the event we are not on your providers panel, we will provide an itemized receipt so you may file the claim for yourself.
If you have a secondary insurance, and the copays or co-insurance is not automatically transferred, you will receive a statement, and you must file the secondary claim. The balance on that statement is your responsibility. Eye Care Associates will do our best to file all necessary insurances, however, there may be instances where it will be your responsibility to file a secondary insurance.
I understand the information above and authorize Eye Care Associates LLC to file a claim with my insurance
I understand that all serviced I received may not be covered benefits as defined by my health and/or vision insurance policies. I have decided to receive these services. I agree to be financially responsible for all services not covered by my health and/or vision insurance policies. I am aware that payment is required in full at time of service.
All sales are final. No refunds on services. Accounts 30 days past due are charged a 1.5% monthly finance charge. The responsible party shall be liable for all collection costs, including but not limited to attorney fees, and court costs.
I understand the information the information above and authorize Eye Care Associates to file a claim with my insurance.