Please list all medications below including prescriptions (examples: pills, inhalers, creams, shots), over the counter medications (examples: aspirin, antacids, diet pills, herbals) vitamins and birth control medications. Include medications taken as needed (example: nitroglycerin, inhalers). If you take more than 10 medications, please bring a current list of medications to your appointment.

Austin Eye has a responsibility to provide quality healthcare services to our patients. In the interest of maintaining a good doctor-patient relationship, we ask that you take responsibility for your financial obligation to our practice. Our policies have been established for our patients and include, but are not limited to, the following:

1. Insurance – Austin Eye will file claims of all applicable visits and procedures. You are responsible for payment of all deductibles, co-insurance and all non-covered services. Please remember that insurance coverage is a contract between the patient and the insurance company. The ultimate responsibility for payment rests with you. WE ARE NOT PROVIDERS FOR ANY SEPARATE VISION PLANS. OUR OFFICE FILES THROUGH MEDICAL INSURANCE ONLY.

2. Referrals and Pre-Authorizations – You are required to 1) know whether or not your insurance requires a referral for medical and/or surgical treatment and 2) obtain that referral before you are scheduled to see our physicians. Our office will assist you in determining whether our doctors are participating or non-participating providers. However, this is not a guarantee of coverage. Our office will not see a patient who does not have a valid referral.

3. No Insurance – Patients who do not have insurance are expected to pay in full on the day that services are rendered. We accept payment with cash, check or credit card (Discover/MasterCard/Visa). We understand that individual situations may make it difficult to meet these financial obligations and we are happy to discuss other payment arrangements as needed. You must make these arrangements before services are rendered.

4. Returned Checks – Your account will be charged $30 for a returned check. You will be asked to provide payment by cash or credit card for the total cost of the returned check and $30 fee.

5. Past Due Accounts – A finance charge of 1.5% per month is assessed on all accounts not paid within 30 days. Patients who have not made an effort to make payment arrangements or have not met their financial obligation will be turned-over to a collection agency. Once an account has been sent to collections, the patient must contact the collection agency for all correspondence regarding the balance. Austin Eye is authorized to automatically collect payment via credit card for any past due balance when credit card information is on file.

6. Refunds – Any refund due to the patient will be given only after all insurance claims are processed. Refunds above $10.00 will be issued to the patient via mailed check; anything under $10.00 will be kept on the account for future use, or can be given to the patient upon patient request.

7. Non-Covered Services – Austin Eye will make an effort to inform you if we believe a service may not be covered by your insurance company. In our professional judgment, these services are needed to render high quality medical care even though they may not be covered by insurance. You will be expected to pay for such services if your insurance company denies payment. Austin Eye is not a provider for separate vision plans. We file strictly through medical insurance. Most medical insurance plans do NOT cover routine eye exams, and most patients do not qualify for routine visits because a medical diagnosis is found. If there is not a medical diagnosis, then the exam will be coded as routine and you will be responsible for any charges not covered by your medical insurance.

8. Appointment Cancellations and No-Shows- As a courtesy to our patients on the waitlist, if you need to cancel or reschedule your appointment, please give our office at least a 24-hour notice of your scheduled appointment time. Failure to give proper notice of cancellation or failure to show for your appointment will result in a $75 charge to your account that must be paid in full before rescheduling your appointment.

9. Direct Assignment of Benefits and Insurance Information – The patient is responsible for providing Austin Eye with current and valid medical insurance. I authorize the release of medical or other information necessary to process my claim. I authorize Austin Eye to initiate a complaint to the Insurance Commissioner for any reason on my behalf.

10. Notice of Privacy Practices: I have been given the opportunity to review the Notice of Privacy Practices (HIPAA).

I have read the above payment policy. I understand my responsibilities for payment of services rendered and will fulfill my financial obligations for services rendered at Austin Eye.

The doctor performs a refraction to determine your glasses prescription. The refraction is also necessary in order to rule out certain eye problems. The refraction test occurs when your doctor shows you a variety of corrective lenses and asks you to identify which lens makes the images being viewed better or worse. A refraction is an essential part of a complete and comprehensive eye examination, but is NOT a covered service by most medical insurance plans regardless of why the doctor performs the test. Please be aware that if this service is performed during your examination, a refraction charge of $75.00 will be collected today in addition to your co-payment.

ACKNOWLEDGEMENT: I have read the above information and understand that the refraction is a non-covered service. I accept full financial responsibility for the cost of this service. I understand the co-pay is separate from, and not included in the refraction fee. I understand I will only be charged this fee when a refraction is done during my examination.

Please list the people you would like the staff at Austin Eye to disclose medical/appointment information to.

Release my protected health information to the following person(s)/entity:

*This consent will be considered valid until such time that I revoke it. I reserve the right to revoke it at any time. I understand that to revoke this consent, I must provide written notice to Austin Eye.

In our effort to provide the most advanced technology available for our patients, Austin Eye is proud to announce the inclusion of the Optomap® Retinal Exam as an integral part of your eye exam today. This exam shows an in-depth view of the retinal layers where disease can start.

 This non-invasive procedure allows your doctor to see a much broader and more detailed view of the retina than possible with conventional methods. In most cases, the Optomap enables your ophthalmologist to obtain a thorough view of your retina WITHOUT the need for dilation of your eyes. When reviewed, the scan becomes a permanent part of your medical file, enabling our physicians to make important comparisons year to year.

 Because of the importance of the exam, our doctors prescribe the Optomap® Retinal Exam for all patients once per year as an essential part of your comprehensive eye exam.

 Insurance typically does not cover any advanced screening technology beyond the general eye exam. Because the Optomap provides useful information about the condition of your retinas and optic nerves, we will be performing this test as an enhancement to the general eye exam for a fee of $75.00.

 Each patient will receive this procedure unless our staff is notified otherwise or unless you decline to have this test performed.

 **Should the Optomap exam reveal medical pathology/disease conditions involving your optic nerve or retina, then your Optomap retinal exams may be billed to your medical insurance for all Optomap exams performed AFTER your initial screening Optomap exam.

Thank you for choosing Austin Eye for your eye care needs!