Patient Forms

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Information Update: New Patient Policy

Date:

Patient Name:

Birth Date:

REFRACTION FEE

One of the most important parts of your eye exam today is the refraction. That is the part of the eye exam by which we determine your best visual acuity and whether you can be helped by new glasses. It is NOT a covered service by Medicare and some plans. Our office fee for refraction is $45.00, and unless your plan covers the refraction charge, this fee is collected at the time of service in addition to any co-payment your plan may require. If you choose not to do the refraction, we will not be able to do a comprehensive exam.

I have read and understand the above refraction policy. X_____________________________________________                                                                                                Signature of Patient or Representative           Date

CONTACT LENS FITTING FEES

Contact lens fitting is charged separately from your eye exam. The fitting fee includes determination of the lens type, curvature and power. Also included are trial contacts as required and visits related to the contact lens fitting for 3 months. The fitting fee varies greatly depending on the type of contact lens and the complexity of the fit. A fitting fee is charged even if there is no change to your contact lens prescription.

The contact lenses are charged separately and our prices are competitive with national suppliers. Contact lenses are not covered by your health insurance.

I have read and understand the above contact lens policy. X_____________________________________________      

Signature of Patient or Representative    Date

 

CANCELLATION AND NO SHOW POLICY

We understand that situations arise in which you must cancel your appointment. It is therefore requested that if you must cancel your appointment you provide more than 24 hours notice. This will enable for another person who is waiting for an appointment to be scheduled in that appointment slot. Office appointments rescheduled or cancelled with less than 24 hours notification are subject to a $40.00 fee. Patients who do not show up for their appointment will be considered as NO SHOW and subject to a $40.00 fee. These fees are the sole responsibility of the patient and must be paid in full before the patient’s next appointment.

I have read and understand the above Cancellation/No Show Policy

X__________________________________________________

Signature of Patient or Representative          Date

 


Information Update: Established Patient

Date:

Patient Name:

Birth Date:

Address Change:

Pharmacy Name and Number:

Daytime Phone Number:

Email:

Primary Care Physician:

Insurance Company:

Any Medication Changes: YES/NO

 

Chief Complaint for Today’s Visit:

 

Has there been any change to your health since your last visit? YES/NO

 

REFRACTION FEE

One of the most important parts of your eye exam today is the refraction. That is the part of the eye exam by which we determine your best visual acuity and whether you can be helped by new glasses. It is NOT a covered service by Medicare and some plans. Our office fee for refraction is $45.00, and unless your plan covers the refraction charge, this fee is collected at the time of service in addition to any co-payment your plan may require. If you choose not to do the refraction, we will not be able to do a comprehensive exam.

I have read and understand the above refraction policy. X_____________________________________________                                                                                                  Signature of Patient or Representative             Date

 

CONTACT LENS FITTING FEES

Contact lens fitting is charged separately from your eye exam. The fitting fee includes determination of the lens type, curvature and power. Also included are trial contacts as required and visits related to the contact lens fitting for 3 months. The fitting fee varies greatly depending on the type of contact lens and the complexity of the fit. A fitting fee is charged even if there is no change to your contact lens prescription.

The contact lenses are charged separately and our prices are competitive with national suppliers. Contact lenses are not covered by your health insurance.

I have read and understand the above contact lens policy. X_____________________________________________    

Signature of Patient or Representative    Date

 

CANCELLATION AND NO SHOW POLICY

We understand that situations arise in which you must cancel your appointment. It is therefore requested that if you must cancel your appointment you provide more than 24 hours notice. This will enable for another person who is waiting for an appointment to be scheduled in that appointment slot. Office appointments rescheduled or cancelled with less than 24 hours notification are subject to a $40.00 fee. Patients who do not show up for their appointment will be considered as NO SHOW and subject to a $40.00 fee. These fees are the sole responsibility of the patient and must be paid in full before the patient’s next appointment.

I have read and understand the above Cancellation/No Show Policy
X_________________________________________                    

Signature of Patient or Representative          Date

 


Financial and HIPAA Policy

FINANCIAL POLICY

As physicians, we are committed to giving you the best possible medical care. To achieve this goal, we need your assistance and understanding of our payment policy. We must emphasize that as your physicians, our primary relationship and concern is with you and your health, not with your insurance company.

Managed Care Plans: As providers we ask that the co-pay and deductibles (if applicable) be paid in full at the time of your visit. We accept assignment for services covered and bill the insurance. Any balance outstanding, following payment from insurance, will be billed to you.

Medicare: We are participating Medicare providers and will file your medical claims to Medicare for you. Services routinely not covered by Medicare (i.e. Refraction/Routine Exams) will require payment at the time of service. We also request payment for the 20% co-insurance of the allowable Medicare charges and any deductible (if applicable) that has not been met at the time of your visit.

Financial Agreement: We will be glad to discuss your proposed treatment and the cost of those services if you have questions about your insurance coverage of a medical service. HOWEVER, please be aware that your insurance is a contract between you, your employer (if applicable) and the insurance company. We are not a party to your contract. Unfortunately, not all services are covered benefits in all contracts.

All charges for services are your responsibility at the time of service. Collection action may be taken for any balance on accounts that are past due. We realize that emergencies do arise and may affect timely payment on your account. If such extreme cases do occur, please contact our office promptly for assistance in management of your account.

If you have any questions regarding the above, any uncertainty regarding insurance coverage or request for payment please do not hesitate to ask. We are here to assist you.

NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding health information. I understand that this information can and will be used to :

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payers.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.

I have received, read and understand your Notice of Privacy Practice containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practice from time to time to obtain a current copy of the Notice of Private Practice.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.

I understand and agree to the financial and HIPAA policies for 1960 Eye Surgeons, PA.

 

________________________________________________________        _________________________________

Patient/Legal Guardian Signature                                                    Date

 

________________________________________________________        _________________________________

Witness                                                                                                           Date

 


Disease and Surgery of the Eye


Joel S. Cohen, M.D.
Anne Chang-Godnich, M.D.
Reem Z. Renno, M.D.
Thomas J. Markus, O.D.
Tessa M. Markus, O.D.
13333 Dotson Road, #200
Houston, TX 77070
(281)890-1784

21216 Northwest Freeway #340
Cypress, TX 77429
(281 970-5346
 

MEDICAL RECORDS RELEASE

I hereby authorize the release/request of my Medical Records or copies of such and request that they are sent to:

Released From:

Physicial Name: _______________________________________________________________________

Address: _____________________________________________________________________________

City: ________________________________________ State:______________ Zip:_________________

Telephone: ________________________________ Fax: _______________________________________

Release To:

Physicial Name: _______________________________________________________________________

Address: _____________________________________________________________________________

City: ________________________________________ State:______________ Zip:_________________

Telephone: ________________________________ Fax: _______________________________________

 

 

Name of Patient: _________________________________________________ DOB: ________________

Dates of Records: From ______________________________ to ________________________________

Patient Signature: ________________________________________________ Date: ________________

 

 

Records copied and mailed/faxed by: _________________________________