Patient Forms

SECTION 4: PATIENT PRIVACY AND PAYMENT AGREEMENT 1. MEDICARE and Other INSURANCE: I request that payment of authorized Medicare/Insurance benefits be made on my behalf to Amedco Kentucky, PLLC dba Precision Eyes, for services furnished to me by Precision Eyes. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services (formerly Health Care Financing Administration) or other Insurance and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim(s). My signature authorizes releasing the information to the insurer or agency shown. I understand that I am responsible for deductible, coinsurance and noncovered services. Coinsurance and deductible are based upon the charge determination of the Medicare or Insurance Carrier. 2. RELEASE OF INFORMATION: I authorize Precision Eyes to disclose all or any part of my medical record and/or financial record for treatment, to receive payment, or for general healthcare operations as covered by HIPAA. This may include information regarding alcohol or drug abuse, psychiatric illness, communicable disease, or HIV. Precision Eyes may also disclose on an anonymous basis any information concerning my case, which is necessary or appropriate for the advancement of medical science, medical education, medical research, for the collection of statistical data or pursuant to State or Federal law, statute or regulation. I authorize and request the disclosure of all protected health information for the purpose of review, evaluation and treatment from any/ all other medical facilities or providers to assist Precision Eyes with the continuation of treatment. This may include records from any other medical provider. A copy of this authorization may be used in place of the original. 3. OTHER INSURANCE: I understand that Precision Eyes maintains a list of health care service plans with which it contracts. A list of such plans is available should I request it. Precision Eyes has no contract, expressed or implied, with any plan that does not appear on the list. The undersigned agrees that I am individually obligated to pay the full charges of all services rendered to me by Precision Eyes if I belong to a plan that does not appear on the above mentioned list. I understand it is my responsibility to verify my insurance coverage and to notify Precision Eyes if any services require precertification. If precertification is required and not obtained prior to a service being rendered, I understand I will be responsible for the bill in full. 4. NON-COVERED SERVICES: I understand that Precision contracts with health care service plans (i.e., HMOs, PPOs) related only to items and services which are covered by the health care service plans. Accordingly, the undersigned accepts full financial responsibility for all items or services, which are determined by the health care service plans not to be covered or not medically necessary. Examples of non-covered services include, but are not limited to, services not specified as being covered in the patient’s contract with a health care service plan or in the benefit summary the health care service plan furnishes to the patient and treatment or test not authorized by the health care service plan. The undersigned agrees to cooperate with Precision Eyes to obtain necessary health care service plan authorizations. 5. FINANCIAL AGREEMENT: I agree that in return for the services provided to the patient by Precision Eyes, I will pay my account at the time service is rendered or will make financial arrangements satisfactory to Precision Eyes for payment within 30 days of receipt of a statement of amounts due by me. I understand if I do not make payment during this time I could be referred for outside collections through a billing service or collection agency. If my account is transferred to either for failure to pay, I understand that I will be responsible for all collection fees associated with collecting my bill in full and interest at a rate up to 18% APR. If my account is sent to an attorney for collection, I agree to pay collection expenses and reasonable attorney’s fees in addition to the collection fees and interest. I understand and agree that if my account is delinquent, I may be charged interest up to 18% APR. Any benefit of any type under any policy of insurance insuring the patient, or any other party liable to the patient, is hereby assigned to Precision Eyes. If copayments and/or deductibles are designated by my insurance company or health plan, I agree to pay them to Precision Eyes. However, it is understood that the undersigned and/or the patient are primarily responsible for the payment of my Bill. The Bad Check NSF Fee is $100. 6. No Show (Less than 24-hour notice): I understand if I fail to cancel/reschedule my appointment 24 hours in advance the following fees will be charged to my account. Office Visits: $10.00 All Surgical/Laser Procedures: $50-$150 7. CONSENT TO WIRELESS TELEPHONE CALLS: If at any time I provide a wireless telephone number at which I may be contacted, I consent to receive calls or text messages, including but not restricted to communications regarding billing and payment for items and services, unless I notify Precision Eyes to the contrary in writing. In this section, calls and text messages include but are not restricted to pre-recorded messages, artificial voice messages, automatic telephone dialing devices or other computer assisted technology, or by electronic mail, text messaging or by other any form of electronic communication from Precision Eyes, affiliates, contractors, servicers, clinical providers, attorneys or its agents including collection agencies. 8. CONSENT TO EMAIL USAGE: If at any time I provide my email address at which I may be contacted, unless I notify Precision Eyes to the contrary in writing, I consent to receiving communications regarding billing and payment for items and services at that email address from Precision Eyes affiliates, contractors, servicers, clinical providers, attorneys or its agents including collection agencies. 9. CONSENT TO PHOTOGRAPHY: I hereby authorize Precision Eyes to take photographs, digital images, or video recordings of me for medical documentation, treatment, education, training, or research purposes. I understand that these images may become part of my medical record and may be used by my healthcare providers to assist in my care. I acknowledge that these images may also be used for educational or research purposes in compliance with HIPAA regulations. If any images are used for purposes beyond my treatment and medical documentation, my identity will be protected unless I provide additional written consent. By signing below, I confirm that I have read and understand this consent form, and I voluntarily authorize the use of my images as specified above. I understand that I have the right to revoke this consent in writing at any time, except to the extent that action has already been taken in reliance on my consent.

NOTE: If Insurance/Medicare doesn’t pay for D. Refraction below, you may have to pay. Insurance/Medicare does not pay for everything, even some care that you or your healthcare provider have good reason to think you need. We expect insurance/Medicare may not pay for the D. Refraction below.

D.	E. Reason Insurance/Medicare May Not Pay:	F. Estimated Cost
Refraction	Non-Covered Service	$35

WHAT YOU NEED TO DO NOW:

• Read this notice, so you can make an informed decision about your care.
• Ask us any questions that you may have after you finish reading.
• Choose an option below about whether to receive the D. Refraction listed above. Note: If you chose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this

This notice gives our opinion, not an official Insurance/Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048) or the phone number listed on your insurance card. Signing below means that you have received and understand this notice. You may request a copy.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OM control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Acknowledgment of receiving a copy of the notice of privacy practices.

*Copies of the HIPAA privacy statement are located at the front desk*