Thank you for choosing our office! Please complete all pages of this form in ink. If you have any questions, please contact us. We’ll be happy to help you!
Note: we confirm all appointments via text or email.
If the patient is a child, please complete the next section:
My signature below provides long term authorization until my written notice otherwise.
TILLAMOOK VISION CENTER FINANCIAL POLICY
We are pleased to discuss our fees with you at any time. Your clear understanding of the financial policy is important to our professional relationship. Please ask us if you have any questions about our fees, financial policy, or your responsibility.
If you have insurance, we will help you receive maximum benefits. We submit claims directly to most insurance companies. If we are billing insurance for you, you can expect to pay your co-payment at the time of service.
If your insurance company has not paid the full balance within 45 days, you will be expected to pay the remaining balance.
If you are covered by an insurance company that we don’t directly bill, you will need to submit the claim yourself. You can expect to pay for your fees in full at the time of service, and your insurer will reimburse you.
Insurance is a contract between you and your insurance company. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, etc., other than to supply factual information as necessary. You are responsible for the timely payment of your account.
We ask that you give 24 hours notice if you are unable to keep your appointment. Patients who fail to give 24 hours notice will be assessed a missed appointment fee.
A service charge of 1.5% or $1.00 minimum per month will be applied to unpaid accounts after 60 days from the date of service. A late charge will be assessed to delinquent accounts.
I have read and understand the financial policy. I understand that I am financially responsible for all charges whether or not paid by insurance.
Acknowledgment and Consent
I understand that Lee Johnson, O.D. of Tillamook Vision Center, TVC OD LLC (referred to below as "this Practice") will use and disclose health information about me.
I understand that my health information may include information both created and received by the practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information.
I understand and agree that This Practice may use and disclose my health information in order to:
I also understand that I have the right to receive and review a written description of how This Practice will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff and other office personnel of This Practice, and my rights regarding my health information.
I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy or a summary of the most current version of This Practice’s Notice of Privacy Practices in effect will be posted in waiting/reception area.
I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests.
By signing below, I agree that I have reviewed and understand the information above and that I have received a copy of the Notice of Privacy Practices.
Note: In order to provide you with the best possible benefit, we need your medicalinsurance information in addition to your vision insurance information.Please bring your current insurance cards to your next appointment.
PRIMARY MEDICAL INSURANCE:
If subscriber is different from you (the patient), please enter the following information:
SECONDARY MEDICAL INSURANCE
Tillamook Vision Center Medical History Questionnaire
Do you have the following:Y: Yes, N: No, P: Past
Do you use:
Family History: Circle member affected F: Father, M: Mother S: Son, D: Daughter
To the best of my knowledge, I have answered these questions accurately. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor of any change in my medical status.
*We know that insurance companies do not always process claims within the legal guidelines. When that happens, we will be happy to file a complaint to the insurance commissioner to get your benefits released. Please sign this letter in the event that claims are unpaid at the prompt payment date on your behalf. Please do not fill in any blanks – only your signature is required at this time. Thank you!*
To Whom It May Concern:
My provider filed the attached claim form with
It has not been paid or denied. It is my understanding that there are state prompt payment laws and/or guidelines that monitor commercial insurance carriers. The State Insurance Department regulates these law and/or guidelines. Tillamook Vision Center’s staff has advised me that they have attempted to resolve the claim on
At this time, reimbursement is still outstanding with little regard to my legitimate rights to have my claim processed within the legal guidelines.
Benefits were assigned to Lee Johnson, OD, and as of today’s date, payment has not been received. As a result, I am responsible for payment of this bill.