Section 1 - Patient Registration Form

PATIENT INFORMATION

***The following questions accommodate our doctor and staff to further provide you with the best possible care***

EMERGENCY CONTACT INFORMATION

INSURANCE INFORMATION

*** If Medical or Vision Coverage is under a different primary, please provide the following information ***Otherwise enter N/A in the field

***Vision Insurance Plans cannot be billed for any patient coming in with a medical eye condition. Vision Coverage is strictly for eye exams and optical services. If you have been diagnosed with a medical eye condition or complaint that may lead to a medical diagnosis this will result in a medical visit and return to office will be required for vision / optical needs. Please provide all appropriate health insurance information upon scheduling or check in. ***

Section 2 - Financial and Insurance Policy

Dear Patient,

Here at EyeSee, we pride ourselves on being a MEDICAL EYE CARE PRACTICE and as such, we strive to provide all our patients with a thorough comprehensive, wellness and prevention, medical grade eye examination, subscribing to the highest standards of medical eye care incorporating the latest advances in diagnostic testing and therapeutic treatments, with the aid of the most cutting-edge technology available.

There are two different forms of insurance coverage used for our eye examinations, Vision and Medical. Vision coverage is designed to merely cover a couple of tests needed to determine a prescription for glasses, and/or fitting of the contact lenses, and help you toward compensation for the optical prescription materials. As such, vision insurance is NOT meant to check eye health for prevention/wellness or diagnostic purposes.

Medical insurance coverage is definitely better equipped to deal with eye health topics of all kinds, from prevention and wellness to complex medical conditions of the body and the eyes.

As a rule, this information is very important for the doctor to obtain in order to provide the best qualitative visual outcome at the end of the eye exam, and certain medical testing is necessary to performed with every one of our eye exams to provide the doctor with the adequate information to check patients' eye health and vision properly.

This is how we are able to maintain the wellness of your eyes, as well as to allow for the timely diagnosis of countless medical eye conditions that may otherwise be missed or be caught too late. For all such testing, MEDICAL insurance needs to be filed. For this reason, and because we are a medical eye care practice, we are REQUIRED to bill BOTH, medical and vision insurances, for every comprehensive eye exam that we provide here at our clinic.

**FOR ROUTINE COMPREHENSIVE EXAMS WITHOUT MEDICAL COMPLICATIONS FOUND, THE MEDICAL TESTING BILLED TO THE MEDICAL INSURANCE WILL BE USED FOR REPORTING PURPOSES ONLY, AND THE BALANCE THAT COMES BACK WILL NOT BE PATIENT’S RESPONSIBILITY.**

Whereas, if any pre-existing or urgent medical or systemic eye conditions are to be addressed at our clinic as a strictly medical eye examination, only MEDICAL carriers (BCBS, Aetna, UHC, Cigna, Medicare, etc.) will be billed, for which the appropriate insurance co-pays and deductible will apply, and any non-covered services or left-over co-pays/deductible amount WILL INDEED BE PATIENT’S RESPONSIBILITY.

We require the payment for such balances to be collected on the day of the exam, and to that end, for the patient's convenience, we work hard to check the insurance benefits prior to your visit.

Please be advised that, BENEFITS QUOTED BY YOUR INSURANCE AGENT ARE NOT A GUARANTEE OF PAYMENT AND WILL NOT BE FINALIZED UNTILL THE CLAIM IS PROCCESED, AS STATED BY YOUR INSURANCE ITSELF.

I understand and will not hold EyeSee liable.

Insurance carriers set these rules and our office is obliged to follow them.

I understand and authorize EyeSee to file my insurance by the above guidelines.