(If patient is a child or COLLEGE STUDENT please complete this section)
Insurance Information (Please give your insurance card to the receptionists with this form)
Do you currently have any problems in the following areas?
Some insurance companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is the patient’s responsibility to pay any deductible, co-insurance and/or any other balance not paid by their insurance carrier. Insurance carriers decide what it considers to be medically necessary or routine based on their own criteria. Most insurance carriers do not cover routine eye exams. Therefore we will not bill routine eye exams and patient will be responsible for payment that day. Please check your plan carefully for covered and non – covered services or benefits.
In order to control billing costs, we request that patients pay for all known non-covered services at the time of service. Patients who have an insurance carrier, with which we do not participate, are required to pay in full at the time of service.
FOR MEDICARE PATIENTS ONLY: Patients with secondary health plans must present proof of insurance on the day of service. If you do not provide proof, you will be responsible to file a claim with your secondary insurance.
Refraction is a measurement of the lens power necessary to prescribe or change your glasses and/or other corrective lenses. Refractions may also be done for diagnostic purposes.
Most medical insurance plans, including MEDICARE, DO NOT COVER A REFRACTION FEE. If your examination includes refraction, there will be a minimum $75 charge DUE THE DAY OF SERVICE in addition to your co-payment.
Contact Lens Agreement
We are happy to assist you with any contact lens issues you may have. All contact lens wearers are required to sign our Contact Lens Agreement before services are rendered.
I request that payment of authorized Medicare and/or insurance benefits be made on my behalf for any services furnished to me. I authorize any holder of medical information to release to the Health Care Financing Administration, its agents, or any insurance carrier I may have, any information as needed to determine these benefits payable for related services.
This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure payment.
It is our goal to provide you the best ophthalmic care we possibly can. Part of your care includes the billing of your services provided we’ve received the correct and complete information from you. If complete information is not provided at the time of your visit, you will be responsible to pay on the day services are provided. Please read the following information as it will answer many of your questions regarding our billing policies.
All Patients: Are expected to have their current insurance card, valid picture ID, Co-pay, Deductible, Co-insurance and any Balance that is due at the time of service.
HMO/Managed Care Plans: It is your responsibility to make sure a current referral has been obtained prior to your appointment with our office. If no referral has been obtained, your appointmentwill be rescheduled. It is the patient’s responsibility to make sure the correct referral is in place, at the time of the visit.
Co-pays: Primary and secondary insurance co-pays must be paid at time of check in. Patients will be asked to re-schedule if they do not have their co-pay at the time of visit.
Late Fees & Collections: Balances greater than 30 days due will accrue a monthly 1.5% late fee. Patients with balances greater than 90 days due will be sent to Collections. Collection fees are anadditional 30% of the balance. We do not permit patients to carry long term balances so a patient may be discharged from the practice for this reason.
No Shows Fees:
Please remember a confirmation call is a courtesy done by this office and not an obligation, therefore it will not be a reason to waive a No-Show fee.
Miscellaneous Charges: There may be charges for the following request
I have read, understand, and agree to the above Financial Policy. I understand that charges not covered by my insurance company, as well as applicable co-payments and deductibles, are my responsibility. I understand that it is my responsibility to contact my insurance carrier(s) if they do not respond to payment request made on my behalf.
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.
You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.
By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, inwriting, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The patient understands that:
In front of __________________________________
OFFICE USE ONLYI attempted to obtain the patient’s signature in acknowledgement of this Notice of Privacy Acknowledgement, but was unable to do so as documented below: