Do you see any of the following specialists?

MEPS does not participate with any Vision insurance plans

(i.e. Davis, NVA, Spectra, EyeMed, VSP, etc.)

As the patient it is your responsibility to provide your accurate medical insurance information. Please have your photo identification and insurance information available at your visit to ensure that your claim can be processed correctly.

PATIENT AGREEMENT:

I agree that Montgomery Eye Physicians & Surgeons, PC may request and use my prescription medication history from other healthcare providers or third-party pharmacy benefit payers for treatment purposes.

I understand that payment is due at the time of service. I certify that the information provided on this form is correct. I authorize the release of information including medical information to this organization and all insurance organizations involved with my care.

MONTGOMERY EYE PHYSICIANS & SURGEONS

OFFICE POLICY & FINANCIAL RESPONSIBILITIES

(read through thoroughly)

APPOINTMENTS:

We request that you keep scheduled appointments and arrive at the scheduled time. If you are unable to keep your appointment, please give at least 24 hours’ notice so that we may offer that time to another patient. Cancellations of less than 24 hours prior to your appointment, or a No-Show for your appointment, will result in a $50.00 fee. If you are late to your scheduled appointment, we will make every effort to accommodate you. However, we may need to reschedule your appointment.

INSURANCES & PATIENT PAYMENTS:

Your claim will be submitted to the insurance that we have on file. It is your responsibility to submit all relevant medical insurance information to us and update it as it becomes necessary. We have no control over how your insurance company processes its claims or if and how much they may pay on a claim. You are ultimately responsible for knowing your benefits and the terms of your coverage. Any amount that is not covered by your insurance is your financial responsibility and you will be billed accordingly.

Copay and any selfpay feesare due at the time of service. If these are not paid before leaving the office, we reserve the right to add an administrative charge of to your account in order to defray the cost of obtaining the copay/fees.

Unfortunately, we DO NOT participate with vision insurance plans. We can check/dispense a glasses prescription (refraction) for you and submit the claim to your medical insurance. However, Medicare and most commercial insurances do not cover this fee. Payment for a refraction is due at the time of service unless we have evidence that your insurance has paid in the past.

ACCOUNT BALANCES:

Any balances that are past due will be assessed a service charge of submitted to a collection agency, a collection fee (30% of the outstanding balance) will be charged to the account. The collection agency will report any unpaid balance to the major credit card bureaus. If for any reason, the account is litigated, you will also be held accountable for all attorney costs and court fees. Fees are subject to change; in that event, you will be notified of such changes.

In the event that this balance should be submitted to a collection agency, a collection fee (30% of the outstanding balance) will be charged to the account. The collection agency will report any unpaid balance to the major credit card bureaus. If for any reason, the account is litigated, you will also be held accountable for all attorney costs and court fees. Fees are subject to change; in that event, you will be notified of such changes.

RETURNED CHECKS:

Any payment made by check that does not clear your bank account will result in a fee for insufficient funds. Our fee is $30.00 and will be added to your account for each returned check.

REFERRALS:

If your insurance plan requires a referral, it must be presented before seeing the physician. If you do not have the required referral, we reserve the right to reschedule your appointment.

FORMS:

There is a $25 fee for any forms that need to be completed by the office. MVA or driver’s license renewal forms will be waived if completed at the time of your appointment.

The physicians and staff at Montgomery Eye Physicians & Surgeons appreciate your confidence in allowing us to participate in your eye care. Your signature indicates that you have read, understand and agree to our office policy & financial responsibilities of our office.

Ocular History

Have you seen any of the following doctors?

Pharmacy Information

Patient Medical History

Montgomery Eye Physicians & Surgeons

Howard Kane, O.D., M.D.

Yun Ja Park, M.D.

Kristen C. Zeller, M.D.

Use and Disclosure of Protected Health Information

PATIENT ACKNOWLEDGMENT & CONSENT FORM

Our Notice of Privacy Practice states that we reserve the right to change the terms described. Should this happen, you will receive a revised copy by mail. You have the right to request restrictions on how your protected health information may be used or disclosed for treatment, payment, or healthcare operations. We are not required to agree to your restrictions; but if we do, we are bound by our agreement with you.

By signing this form, you consent to our use and disclosure of protected health information about your treatment, payment and health care operations. We will mail to your home a recall card to notify you that you are due for another appointment. You have the right to revoke this consent in writing, except when we have already made disclosure in trust on your prior consent.

I request the payment authorized Medicare/Insurance carrier benefits be made on my behalf to Montgomery Eye Physicians & Surgeons, P.A. for any service furnished to me by that physician or supplier. I authorize any holder of medical information about me to be released to the Centers for Medicare/Medicaid Services and it’s agent and/or any other insurance carriers for which have coverage, any information needed to determine these benefits or the benefits payable for related services, I agree to provide all referral and treatment plan(s) as required by my insurance carrier(s All co-pays must be paid at time of service in accordance with the contracted insurance carrier agreements. In order for our office to effectively communicate with you, please complete the following. You may update your selections at any time.

Please indicate below who we may discuss your medical information with. Include the individual name, relationship to you, and phone number. The individual listed will only be contacted with your consent.

{nameRelationship}

{nameRelationship17}

I consent to staff (physicians, technicians, or office personnel) of Montgomery Eye Physicians & Surgeons to leave voicemails on my phone regarding appointments, my care and/or test results.