PATIENT INFORMATION

I consent to receive medical care and treatment from Eye Care Specialists and its providers. I authorize Eye Care Specialists to bill my insurance for services provided and assign payment of benefits directly to the practice. I understand that I am responsible for any costs not covered by my insurance, including copayments, deductibles, or non-covered services.

Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portabilitiy and Accountability Act, 45 C.F.R Parts 160 & 164).

1. I authorize Eye Care Specialists, P.C. to use and disclose the protected health information, to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews.
2. This authorization for release of information covers the period of healthcare from: all past, present and future periods.
3. I authorize the release of my complete health record, including records relating to mental healthcare, communicable diseases, HIV or AIDs, and treatment of alcohol or drug abuse.
4. I understand that I have the right to revoke this authorization in writing at any time. I understand that revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authoirization was obtained as a condition of obtaining insurance coverage and the isurer has a legal right to contest a claim.
5. I understand that information being used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. 
6. I hereby acknowledge that I received a copy of Notice of Privacy Practices. 

I understand that by signing this form, I have read and agree to the HIPAA Privacy Authorization Form and it will remain in effect for this and all future visits/ treatments with Eye Care Specialists, P.C.

I have received, read, understood, and hereby agree to the Eye Care Specialists, P.C. Patient Financial Policy as stated below. 

• I understand that charges not covered by my insurance plan, as well as applicable copayments and deductibles are my responsibility.
• I understand that Eye Care Specialists, P.C. maintains a list of health care service plans with which it contracts. A list of such plans is available from the business office. And that Eye Care Specialists, P.C. has no contract, expressed or implied, with any plan that does not appear on the list. I understand that I am individually obligated to pay the full charges of all services rendered to me by Eye Care Specialists, P.C.if I belong to a plan that does not appear on the above mentioned list.
• I understand that repeated missed appointments may result in my inability to make future appointments.
• I understand that it is my responsibility to be familiar with my insurance plan and what benefits it provides. This includes what copayment and deductable amounts are and when I need to obtain referrals and authorizations prior to treatment.
• I authorize my insurance plan to assign and/ or pay benefits directly to Eye Care Specialists, P.C.
• I authorize Eye Care Specialists, P.C. to release pertinent medical information to my insurance company when requested, or to facilitate payment of a claim.
• I understand that my bills need to be paid to Eye Care Specialists, P.C. within 60 days. 
• I understand that if my account is past due after 60 days that my account may be referred to a collection agency if I have not set up a scheduled payment plan.
• I am responsible for all costs incurred/ associated with the collection of any amount past due to Eye Care Specialists, P.C.
• I understand that if I do not have insurance coverage (self-pay) that I am responsible for payment in full of all charges associated to my treatment at Eye Care Specialists, P.C.

I understand that by signing this form, it will remain in effect for this and all future visits/ treatments with Eye Care Specialists, P.C.

Definition of REFRACTION: The refraction test is an eye examination that measures a person's ability to see an object at a specific distance. Your eye doctor can determine if you have any visual conditions and help confirm the extent of vision difficulty, and can determine if a person has normal vision. When a person complains of blurry vision, this test can help determine the extent of poor vision. It can also be performed to help follow the progress of treatments for diseases of the eye such as cataracts. The test is also used to prescribe glasses if needed, and ensure the prescription for eyeglasses or contact lenses to be correct for each patient.

Medicare and most commercial insurance plans do not cover this service. If your eye doctor determines that you will need to have a refraction performed and your insurance does not cover it, you will be held responsible for paying that portion of the exam fees along with any other charges you are normally responsible for (copayments/ deductables). Our refraction fee as of January 12, 2022 is $45.00.

I understand that by signing this form, I have read the form and agree that: the refection may not be a covered service under my health insurance plan. I agree to pay any fees related to this non-covered service along with any other fees required by my insurance plans (copayments/ deductables).