Miller Vision Patient Forms

Name

First NameLast Name
Birthdate
Address

Street Address

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CityState / Province

Postal / Zip Code
Phone number

Email
Diabetic doctor (if diabetic)
List Eye Surgeries
Occupation
Insurance Name
Insurance ID number
SSN* optional
Eye Health: Do you have any of the following? Please check the box*

CataractsDouble VisionDry EyesEye PainFlashes/FloatersForeign Body SensationGlaucomaLight SensitivityMacular DegenerationMucus DrainageRed EyeRetinal IssuesSandy/GrittySorenessStye/ChalazionVision ChangesWatery EyesNoneOther
Medical Health: Do you have any of the following? Please check the box*

AllergiesArthritisAsthmaAutismCancerElevated CholesterolDementiaDiabetesHeadachesHeart DiseaseHigh Blood PressureKidney DiseaseLupusMental IllnessMultiple SclerosisRheumatoid ArthritisThyroidNONE
List all medications you are currently taking *
Please list any medications you are allergic to *
Family History of Eye Disease
Migraines

1-Never2-Rarely3-Sometimes4-Very Often5-Always
Headaches-'of any severity each week, usually getting worse later in the day'

1-Never2-Rarely3-Sometimes4-Very often5-Always
Discomfort with Computer Use- 'In your eyes (redness,burning) after long hours looking at the screen

1-Never2-Rarely3-Sometimes4-Very Often5-Always
Tired Eyes-'With increasing feeling of eye fatigue throughout the day'

1-Never2-Rarely3-Sometimes4-Very Often5-Always
Motion Sickness-'or an experience like dizziness or vertigo'

1-Never2-Rarely3-Sometimes4-Very Often5-Always
Are you a Smoker? *
Do you drink Alcohol?*
We accept the following insurance plans: Aetna, Blue Cross Blue Shield, Blue Med, Community Eye Care, Eye Med, Health Team Advantage, Medicare, Medicare Complete, United Healthcare, UMR, and VSP. If your plan is not listed, we may be out of network and charges will be patient responsibility.

We accept the following insurance plans:

Aetna, Blue Cross Blue Shield, Blue Med, Community Eye Care, Eye Med, Health Team Advantage, Medicare, Medicare Complete, United Healthcare, UMR, and VSP. Please list your insurance provider.

If your plan is not listed, we may be out of network and charges will be patient responsibility.
What is the name of your Medical Insurance?
List name and birthdate of policy holder
List names of authorized family members to release patient information
Good Faith Estimate FEES and SERVICES: Some fees are not covered by your insurance. Please be advised these fees are patient responsibility. Those include Optos imaging and refraction vision check. Those tests are performed on every complete eye exam regardless of medical or routine vision coverage. New patient exam $204/ Existing patient exam $153/ Refraction vision check $35/ Optos photo imaging $29/ Photos $85/ Visual Field $85/ OCT $85/ Pachymetry 76514 $36/ Gonioscopy 92020 $50/ Epilation 67820 $60/ Contact lens annual exams $87-$125/ Specialty Contact Lens Fitting $400-$850

Disclaimer
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill. If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. To learn more and get a form to start the process, go to www.cms.gov/nosurprises/consumers or call 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate of the dispute process, visit www.cms.gov/nosurprises/consumers or call
1-800-985-3059.

Advance Beneficiary Notice

ABN: SOME FEES ARE NOT COVERED BY YOUR INSURANCE.

PLEASE BE ADVISED THESE FEES ARE PATIENT RESPONSIBILITY.

Those tests are performed on each exam regardless of medical or routine exam diagnosis.

If you are scheduled for special tests please note, insurance companies may not pay for certain tests and materials. Refraction $35/ Photos $85/ Visual Field $85/ OCT $85/ Specialty Contact Lens Fitting $125-$850. If my insurance company denies payment, I understand that I am responsible for non-covered services. Ask your assistant for fee information before you are tested if you are concerned your insurance may not pay.
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ABN: Advance
Office Policies: Payment and Fees: Payment is expected at time of service for fees not allowable by your insurance carrier. Insurance companies do not guarantee payment. Any additional balance will be billed to your account. We do not file secondary insurance. Assignment of Benefits: I hereby assign all medical and/or vision benefits, to which I am entitled, from my insurance plan to Miller Vision Specialties. Authorization to Release Information: I authorize Miller Vision Specialties to release all information pertaining to patient treatment to his/her insurance companies and to any other physician or health care provider to whom the undersigned may be referred. Consent to Treat: I authorize medical treatment of myself/minor by the physicians of Miller Vision Specialties. Prescription Release: Notice of prescription release requirement of contact and glasses for complete eye exams and contact lens fittings. Prescription received. Notice of Privacy Practices: I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can be used to: *Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. *Obtain payment from third party payers. *Conduct normal healthcare operations such as quality assessments and physician certifications. A copy of the Notice of Privacy Practices containing a more complete description is available within the office. I understand this office has the right to change the Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy.

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Spectacle/Contact Lens Prescription Release Notice

Pursuant to the Federal Trade Comission's ruling 16 CFR Part 315:I understand that the practice will readily supply a copy of my non-expired Spectacle or Contact Lens prescirption at my request. To abide by HIPAA guidelines, in the absence of a secure electronic submission portal, I understand that this prescription will be available to me by fax or postal mail, or that I may request to pick up the document at the office (allowing a reasonable time frame for office staff to obtain the doctor's signature).
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Lifetime Authorization for Insurance Payments

Your signature on file and proof of identity is requested by this office in order to file insurance for you for any office procedure. Refusal to do so will require cash payment and you will be provided a detailed receipt. I request that payment of authorized carrier of benefits be made on my behalf to this eye doctor for any services furnished to me by this/these doctors. I authorize any holder of medical information about me to be released to the carriers needed to determine benefits or the benefits payable for related services.
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