Patient Information

Meaningful Use

Ocular Surgery

Social History

Family History (please check all that apply)  M=Mother F=Father B=Brother S=Sister

Review of Systems: Are you currently experiencing any of the following? (please check yes or no)

Alerts: Are you currently experiencing any of the following? (please check yes or no)

Assignment of Benefits

INSURANCE

I hereby authorize The Eye MD to apply for benefits on my behalf for covered services rendered. I certify that the information I have reported with regard to my insurance coverage is correct. I further authorize the release of any necessary information, including medical information for this or any related claim, to my insurance carrier, (or, in the case of Medicare Part B benefits to the Social Security Administration and Health Care Financing Administration). 

A copy of the authorization may be used in place of the original. This authorization may be revoked by either me or my insurance carrier at any time.

ASSIGNMENT OF BENEFITS

I hereby authorize payment of all medical insurance benefits which are payable to me under the terms of my insurance policy to be paid directly to The Eye MD for services rendered. I further authorize the release of any information needed for processing my insurance claims. A copy of this authorization may be used in place of the original. I understand and agree that I am financially responsible for charges not paid by my insurance company.

Returned Check Fee

I understand that if my check is returned for insufficient funds, I will be charged a fee of $50.00 plus the original amount due.

Appointment Policy

If you are unable to keep a scheduled office visit appointment, we ask that you please give us at least 24 hours notice. “Late Cancellation” or “No Show” appointments may be charged a $50.00 fee.

Refraction Fee Policy

Refraction – or the determination of an eyeglasses prescription – is routinely performed in our office. This is one of the most important parts of your eye examination. It is how we determine the best possible visual acuity and function of your eye. It is NOT part of the medical examination fee for an ophthalmologist. Medicare and many other insurance plans will not pay for the refraction service. 

You may need a refraction if you are experiencing any of the following problems:

• Blurry vision
• Trouble reading
• Current glasses are not strong enough
• You have never been seen by an eye doctor and your vision is not 20/20
• You have been told that you have cataracts
• The doctor finds that you are not 20/20
• Other reasons for which the doctor will discuss with you
• Cataract check

It is our experience that many insurance plans consider this a “ vision-related” service, not a “medical” service and do not cover this. Medical insurance companies base their decision to pay on the member’s specific plan benefits, which differ greatly. Due to time constraints, we are unable to check this in advance of your visit to the office. Our refraction fee is $65.00.

Our office policy is to collect the refraction fee at the time of the visit. We will bill your insurance company for the refraction. If your insurance company pays us for the refraction, then we will refund you this payment, minus any financial responsibility you have such as co-insurance or deductibles.

Authorization for the Use or Disclosure of Protected Health Information

This is a summary of our Notice of Privacy Practices. The entire text detailing our privacy practices is available for your review, and we encourage you to read it and ask any questions you may have regarding our privacy practices. If you have any questions or would like to exercise any of your rights, please contact our Privacy Officer. After reviewing the materials, please sign in the space provided below.

PATIENT RIGHTS

As a patient, you have a right to inspect, copy, amend, request a restriction, or revoke a prior restriction on the use and disclosure of your Protected Health Information (PHI). You may request a copy of any accounting of disclosures, which will detail all disclosures made for reasons other than treatment, payment, or health care operational purposes. You may request that we communicate with you only in a specific manner (i.e. “only communicate with me at my work telephone number”).

PROVIDER RIGHTS

As your health care provider, we can use or disclose your PHI for treatment, payment, or health care operational purposes. Any other disclosure requires you to sign a specific authorization.

Patient Contact Authorization

In general, the HIPPA privacy policy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI is made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.

I wish to be contacted in the following manner (check all that apply)

You may discuss my medical history with:

The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by the individual. Healthcare entities must keep records of PHI disclosures.

To assist us with this requirement, our office will only release information with a written request signed by the patient or legal guardian of said patient. This includes requests made by other physicians and their office(s). Our office will supply the proper form.

Note: Uses and disclosures for PHI may be permitted without prior consent in an emergency. All authorizations will be in effect until revoked in writing by the patient.