HIPPA

Payment Responsibility Statement

And

PRIVACY NOTICE ACKNOWLEDGEMENT

I am here for an eye health and vision examination.  If I have healthy eyes and no risk factors, all testing will be covered as part of this healthy eye examination; except the Optomap which is a $37 routine test not covered by most insurances.  If I have eye health disease or risk factors, additional testing not covered in the healthy eye examination fee may be necessary to determine if and what treatment is needed.  The doctor will discuss any additional tests.  Charges for these tests will be submitted to my health insurance.  Any deductibles, copayments, or non-covered services are my responsibility.

As required by Federal Law, Eyecare Associates has made its Privacy Notice available to me. The notice summarizes ways my Protected Health Information may be used and disclosed. 

I have read and acknowledge the above statement regarding responsibility for payment and understand the privacy notice.

Medical vs Vision Insurance

Most people have both vision and medical insurance.  They are very different in terms of the services that they cover and it’s important to understand those differences.  Vision coverage is mainly designed to determine a prescription for glasses, help pay for glasses or contacts, and to screen for medical conditions.  It is not designed to be used for medical conditions, diagnostic or screening tests or treatment plans.  Some medical plans have a vision benefit.

When a medical diagnosis or condition is present (such as diabetes, high blood pressure, etc.) or an eye disease ( glaucoma, dry eye, allergies, cataracts, macula degeneration, etc.) it is necessary to file the claim for your appointment to your medical plan and the co-pays, co-insurance, non-covered services and deductibles apply.  Vision insurance does not cover medical eye problems.  Our office does not make the rules; they are defined by insurance carriers and we are required to follow them.

In most cases, it is difficult to know prior to your examination, which type of insurance will apply or with who our office will be able to file a claim for you.  We make every effort to determine as much information for you in advance.

I understand the above information and authorize Eyecare Associates to file a claim on my behalf and I understand that I am responsible for any co-pays, co-insurance or a deductible that has not been met.