Niagara Eye Associates

I authorize the release of any medical information necessary to provide the most beneficial and complete visual examination. I understand that I am financially responsible for all charges whether or not paid by insurance. Payment is due at the time services are rendered.

 

There may be times when we would like to informally contact you with information, or when you may want us to tell others, such as family or friends, about your condition or treatment.

For instance, we may need to contact you to report test results or you may want us to inform your family of how your treatment is proceeding. We refer to this type of informal communicaton as "Personal Communication". Please fill out this form to help guide us in providing Personal Communication about you.

 I understand the following with respect to this form:

• I may refuse to complete/sign this form. My refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits.

• If the person(s) receiving information about me through Personal Communication is not a health care provider or a health plan covered by Federal Privacy Regulations, the information may be re-disclosed and no longer protected by Federal Privacy Regulations.

• I may change or revoke this form in writing at anytime, for future Personal Communications.

Advance Beneficiary Notice (ABN)

We expect that your insurance plan may not pay for the item(s) or service(s) that are described below, therefore we are collecting the payment of $50.00 in advance. If, by chance, your insurance plan covers the refraction (92015) we will reimburse you the fee of $50.00. If your insurance plan does not pay for that service you should still be entitled to receive a refraction, especially if it is recommended by the doctor.

A refraction is when you are examined for a new prescription for eyeglasses and are physically handed a prescription. Unfortunately, most insurance plans do not feel a refraction is medically necessary.

The purpose of this form is to help you make an informed decision as to whether or not you would like to receive this service, with the understanding that you may be expected to pay for this service.

Feel free to ask a technician for clarification if you do not understand the content of this form.

Please choose one of the following options by checking the relevant box, then sign and date below.

In addition, contact lens fitting fees are not covered under medical insurance, therefore a fee will incur if you elect to proceed with a contact lens fitting/exam. Please ask technician for details.