Patient Forms To Complete Before Visiting
The following forms can be downloaded to your computer and printed at home. Please fill out the following patient information form which includes your contact and insurance information, and download and review our private practice policy. If you have any questions when filling out these forms, please do the best you can and our staff will assist you with your questions on the day of your visit.
New Patient Paperwork
Notice of Privacy Practices
Post Retinal Surgery Instructions
Instructions After Injections
Medical Record Release form
Medical Record Release Form Patient
We are dedicated to providing the best possible eye care and service to you and regard your complete understanding of your financial responsibilities as an essential element of your care and treatment. Thus, in order to reduce confusion and misunderstanding between our patients and the practice, we have adopted the following financial policy. Unless other arrangements have been made in advance by either yourself or your health coverage carrier, full payment is due at the time of services.
We have made prior arrangements with many insurers and other health plans to accept an assignment of benefits. We will bill those plans with whom we participate, and will only require you to pay the authorized copayment at the time of service. It is the policy of our office to collect the copayment when you arrive for your appointment. All copayments not paid at the time of service will be billed an additional $5 to cover administrative costs.
Managed care and HMO insurance companies have many rules and regulations. Because we participate in over 70 insurance plans, we can no longer be responsible for ensuring your compliance with your insurance company rules. However, to the extent possible, we will still attempt to assist you in your efforts to understand and comply with your insurance company’s requirements.
If you are in a Managed Care Plan or HMO, please make sure you are aware of the following information:
- Is a referral from your primary physician needed?
- Does your referral cover more than this visit?
- When does your referral expire?
- Does your insurance company cover routine eye exams?
- What clinical lab is contracted with your insurance company?
In the event your health plan determines a service to be “not covered”, you will be responsible for the complete charge. Refractive testing is reported separately with other visual examination, although Medicare and some private payers do not cover this service. Please contact your insurance company directly for the answer to these and other questions. You are ultimately responsible to know your own insurance policy and their limitations. If you have any questions, please discuss them with our office manager.