Basic Patient /Consent Treat

Consent to Treat

Basic Health Information

Patient Name

First NameLast Name

Birthdate

Date

Required Yearly Consent Form*

I understand this form must be updated yearly.

Consent to Treat: I hereby authorize Drs. Hawks, Besler, Rogers & Stoppel (Drs. HBRS) to treat me/my child.

Requirements at time of service: I understand insurance cards must be presented at time of service or the patient will be self-pay until cards are presented or if insurance changes within treatment, cards must be presented before Drs. HBRS will file claims to new insurance. All CO payments, co-Insurance, deductibles, and non-covered services are due at the time of service. Not all services are a covered benefit. If your insurance company denies a service, the balance is due within 30 days. Verification of benefits is not a guarantee of payment. We do offer a discount on certain services if paid in full at the time of your appointment and if no insurance is filed.

Assignment of Insurance Benefits: I hereby authorize and assign, my insurance carrier(s), to make payment directly to Drs. HBRS of insurance benefits for services herein specified and otherwise payable to the insured. Drs. HBRS files both primary and secondary insurance as a courtesy to patients for the companies with which we participate. I understand and agree that I am financially responsible for Drs. HBRS for all charges incurred regardless of potential insurance benefits including but not limited to CO payments, deductibles, and non-covered services. I understand Drs. HBRS will not become involved in disputes between the patient and the insurance company. I understand it is my responsibility to verify with my insurance company the physician(s)treating me are covered under my insurance and to get referrals and/or authorization for services.

Minor Patients: Any patient under the age of 18 should be accompanied by a parent/guardian. I understand by signing HBRS' financial policy, I am solely responsible for any incurred charges for the below named patient. The parent who brings the child in for care is ultimately responsible for their bill and we will not get involved in support disputes.

Returned Check Fee: I understand that if Drs. HBRS receives a returned check, I will be charged $30 plus the amount on the check and I will be on a cash-only basis thereafter.

Non-Payment: We reserve the right to send an account to collection if not paid in full. If Drs. HBRS refers your account over to a collection agency you will be responsible for your balance plus the collection agency fee of 25%.

*

I acknowledge that I have reviewed a copy of Drs. HBRS' Notice of Privacy Practices

Medicare General Rules

Our office is a participating provider for Medicare. Medicare requires that you pay the annual deductible toward any qualified services before Medicare will pay for any services. Our doctors accept assignment on your bill and we will file, via electronic transmission or paper claim, directly to Medicare. You will be responsible for any remaining amount they do not pay. As a courtesy to you, we will file any supplemental insurance.

A. Medicare does not cover eyeglasses or contact lenses unless you have had cataract surgery.

B. Medicare does not cover the refraction part of the eye exam.

C. Medicare does not cover any services without a medical diagnosis. The need for glasses is not considered a medical diagnosis.

*

I understand my responsibility to Medicare

Kansas Medicaid Advanced Beneficiary Notice

This constitutes Notice to you, the beneficiary, that if Drs. HBRS meets all

program requirements and payment is not made by KanCare, you may be

held responsible for the charges if your services or materials are not covered

by KanCare. This includes but is not limited to the eye exam, frame, lenses,

coatings, or medically necessary contacts.

CONTACTS AND CONTACT LENS SERVICES ARE NOT A COVERED

BENEFIT OF KANCARE (except United Healthcare KanCare)

*

I understand my Medicaid Benefits

I do not have Medicaid insurance

Contact Lens Wearers

I acknowledge that I will receive a copy of my current contact lens

prescription from Drs. Hawks, Besler, Rogers & Stoppel thru email, fax, Printed copy or Portal.

*

I understand I will receive my Contact Lens prescriptionDo not wear Contact Lenses

Disclosure to Friends/Family Members

If a designated family member or another individual may discuss your Private Health Information (PHI) with the doctor, please list them below. The patient may revoke or modify this specific authorization and that revocation or modification must be in writing.

This includes things like scheduling an appointment, picking up your glasses/contacts or obtaining copies of your prescriptions. If you list no one, you will be the only one we may speak to for any of those things.

I give permission for my Protected Health Information to be disclosed for purposes of communicating results, findings, and care decisions to the family members and others listed below:

I authorize the person below to have access to my Private Health Information (PHI)

Full Name

First NameLast Name

Relationship

Phone Number

Please enter a valid phone number.

Full Name

First NameLast Name

Relationship

Phone Number

Please enter a valid phone number.

Full Name

First NameLast Name

Relationship

Phone Number

Please enter a valid phone number.

*

Clear

At times, Drs. HBRS will publish and use photos and video of eye exams, eyewear fittings, eyewear dispensing, or related activities, which may be used, nationally and internationally, in any media, including social media without compensation.

Type a question*

I do give permissionI do not give permission

Authorized Contact

Marketing Permissions