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Referred By:

Scheduled For:

Primary Concern Today:

Are we billing your medical insurance for any medical eye problems or follow up treatment today?

Primary Insurance

Secondary Insurance

Vision Plan

I hereby authorize Advanced Eye Care to provide a diagnosis & optometric treatment to my child or me. I further authorize the release of Protected Health Information to additional physicians or optometrists in order to facilitate continuity of care. I have read & understand the above information & am signing this form voluntarily.

I authorize the release of all necessary Protected Health Information & assign all medical & vision benefits to Advanced Eye Care. I also request that payment of authorized Medicare (if applicable) benefits be made on my behalf to Advanced Eye Care for any services furnished to me by Advanced Eye Care. I authorize any holder of medical information related to me to release to the Centers for Medicare & Medicaid Services (CMS) & its agents,any information needed to determine these benefits or the benefits payable to related services. I understand that my signature requests that payment be made & authorizes release of medical information necessary to pay the claim.If item 12 of the CMS 1500 claim form is completed, my signature authorized releasing of the information to the insurer or agency shown.In Medicare assigned cases, the supplier agrees to accept the charge determination of the Medicare carrier as the full charge, & the patient is responsible only for the deductible, copay, & non-covered services. Copay & deductible are based upon the charge determination of the Medicare carrier. I understand that I am ultimately responsible for any bill incurred in this office. Should this account become delinquent, I will be responsible for any & all legal fees, court costs, & collection charges.There will be a service charge for each returned check. This authorization & assignment will remain in effect until revoked by me in writing. A photocopy of this authorization & assignment is to be considered as valid as the original. I request that you file my insurance & I have agreed to & completed all of the conditions listed above. I accept financial responsibility for all charges. I have read & understood this information & I am signing voluntarily.

1. Proof of Insurance: Providing quality medical care is our primary goal. We participate with most insurance programs as a service to you. You, the patient, have the ultimate financial responsibility for services rendered. If you do not provide proof of valid insurance at the time of service, you will be responsible for all fees upon checkout.

2. Coverage and Benefits: Most medical insurance companies do not cover annual vision exams. Some insurance plans offer routine coverage, if you have questions regarding your coverage benefits, please direct them to your employer or your insurer’s representative. It is your responsibility to inform us of any secondary benefits of special requirements, such as Worker’s Compensation, or you will be financially responsible for services rendered. Please provide proof of any medical and vision coverage.

3. Payment is due when services are rendered: You are responsible for all co-pays and deductibles required by your insurance contract. Co-pays or co-insurance need to be paid the day services are rendered. Any non-covered services or treatments that you request or your physician recommends are also your responsibility. If you do not have insurance, all fees are due at the time of service. We accept Visa, MasterCard, Discover, CareCredit, Cash and Checks.

4. Billing, Payments, and Over Payments: If an overpayment is made by you, a refund will only be issued if there are no other outstanding debts on you or your family’s account. Please inform us of changes in address, phone or employer.

5. Returned Check Policy: You may be billed a $35.00 returned check fee or any fees that we incur as a result of your check being returned to our bank.

6. Retail Goods Policy: Optical orders (including but not limited to glasses, glasses lenses, contact lenses and/or low vision aids) will not be placed without a deposit of half of the total. Glasses must be picked up within 30 days of notification or any deposit could be forfeited. If orders are cancelled, the patient will be responsible for any lab and/or restocking fees. If any products are paid in full and not picked up within 90 days, they will be mailed to the address on file. We are not responsible for items lost or damaged in the mail.

7. Refraction: Medicare and some plans do not cover this service. You will be responsible for a fee of $45.00 should this apply to you.

8. Cancellation Policy: When an appointment is scheduled, that time has been set aside for you and when it is missed, that time cannot be used to treat another patient. We require that you give our office 24 hours notice in the event that you need to reschedule your appointment. This allows other patients to be scheduled into that appointment. If you miss an appointment without contacting our office within the required time, this is considered a missed appointment. A fee of $25.00 will be charged to you; this fee cannot be billed to insurance and will be your direct responsibility. Additionally, if a patient is more than 15 minutes late without prior notice for a scheduled appointment, we will consider this a missed appointment and the $25.00 cancellation fee will be charged.

Many of our patients are fortunate to have excellent insurance. The problem is that it can be confusing and sometimes challenging to understand it all. We want to make this more clear!

An optometrist is a medical doctor (just like your family doctor or cardiologist) and provides very comprehensive, medical eye exams. However, optometrists also provide routine vision exams for people with no eye disorders.

Our certified billers will determine the appropriate plan (medical or vision) to file your claim, based on the results of your exam and the requirements of insurance payors. Below are some general guidelines that we follow.

For Patients with BOTH Medical and Vision Coverage
Your vision benefit is intended to provide you with a “routine” vision eye exam. If you are being evaluated for a medical reason/complaint (corneal disorders, diabetes, cataracts, glaucoma suspect, double vision, doctor’s referral, etc.), you are being provided with medical care. Vision Plan benefits do not provide coverage for medical care. Therefore, we will file a claim with your medical insurance for visits related to medical complaints and problems. (We will inform you IF both plans can be used on the same day.) Medical evaluations take more time. And doctors are required to bill a medical provider for this type of service.

For Patients without Vision Coverage
If you are being seen for a routine eye exam and do not have vision coverage, your medical insurance will not pay for the exam. However, if you have a medical problem (corneal disorders, diabetes, a lazy eye, cataracts, glaucoma suspect, double vision, etc.), your visit is considered a medical problem and can be billed to your medical plan.

When your visit is for a routine eye evaluation, we will follow your plan’s guidelines collecting applicable copay and/or co-insurance at the time of service.

Your copay today is due at time of service.

Do you wear glasses?

What difficulties are you having with your current glasses?

Do you have a spare or backup pair of glasses?

What do you use for your everyday sun protection?

If you’re a candidate for full time or occasional wear contact lenses would you like to know?

Do you wear contact lenses?

How many hours per day do you generally wear your contact lenses?

How often do you discard your contact lenses?

What type of solution do you use?

Do you use contact lens rewetting drops?

Any changes to your night-time vision?

How many hours a day do you focus on a digital screen, like a computer, iPad, or other electronic device?

Are you experiencing any floaters?

Are you experiencing any flashes?

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