Patient Forms

Insurance:

• To ensure proper billing, it is your responsibility to notify us of ALL of your insurance coverages, both Vision Plans and Medical Plans (Including any Medicaid Plans). Without this accurate information you are responsible for all fees associated with examination and orders and will have to submit to your insurance for reimbursement.

• You are responsible for any and all charges for services and materials rendered including copays, unmet deductibles and procedures that are not covered by your insurance.

• Your “reason for visit” will determine what insurance needs to be billed as primary. If there is a possibility of coordinating insurance coverages we will do so.

• If you have specific questions or concerns regarding your insurance plan and its coverage please contact your insurance company directly or human resources at your place of employment.

Medical Exams Vs Routine Vision Exams and Refraction:

Routine Vision or "Well Vision" exams are for people who have no eye disease or symptoms of disease. Your eyes will be examined for any needed correction (glasses or contact lenses) or any potential indicators of eye disease. If Dr. Einig finds anything abnormal during your vision exam, further testing of a medical nature may be needed at another visit. In that case, your medical insurance would be billed.

Medical Exams (where your medical insurance will be billed) are performed for the diagnosis and treatment of diseases and conditions of the eyes as well as monitoring known eye related conditions. This exam evaluates the reasons for the symptoms and assesses any treatment needed. Some conditions evaluated with medical eye exams (medical insurance will be billed as primary) include but are not limited to the following: diabetic eye exam, dry eye, eye allergies, cataracts, glaucoma, macular degeneration. Emergency visits such as sudden loss of vision, change in vision, flashes or floaters symptoms, “red” eyes, scratches on the eye, foreign material in the eye are also medical evaluations.

• Vision exams do not qualify for prescribing medications that have to be filled at a pharmacy.

• Diabetic eye exams will not be billed to a vision plan as the primary payor. In some cases it can be billed as secondary to medical coverage for coordination of benefits.

• Special testing in office always has to be billed to medical insurance as primary payer

*****A refraction is often needed to evaluate ocular health and progression of complications even when eyeglasses are not prescribed . Most Medical Insurance companies (including but not limited to Medicare and Priority Health) will not pay for this procedure and will be the patient's responsibility on examination day.****

HIPAA Policy:

I acknowledge that I have been made aware of the public location of the notice of privacy practices within the reception area of Northwest Optometry and/or have received a copy of the “notice of Privacy Practices” upon my request. I also acknowledge that this information is available for me to view at www.northwestoptometry.com

Financial Responsibility, Payment Options and Requirements:

• All Copays are due on the day of examination. If there is no Insurance to be billed all services are required to be paid in full on the day of examination.

• We accept cash, checks, credit cards, health savings account cards, “Sparta Bucks” and gift certificates generated from Northwest Optometry as a form of payment.

• “NSF” checks will incur a $40.00 fee in addition to the outstanding balance

• Outstanding balances are due within 30 days of receiving a statement. If you are unable to make a full payment contact the office for payment arrangements.

• For our pediatric patients whose parents are currently divorced or separated. It is our policy to set the account up for a minor under the parent that is the insurance coverage policy holder. Payment is due on the day of examination by whatever party brings the patient to the examination.

I authorize any holder of medical or other information about me to be released to my insurance carrier or the Social Security Administration. This would include payment information for related claims. I permit a copy of this authorization to be used in place of the original to request payment. I request that payment of authorized private insurance company benefits, Medicare and Medicaid services or other applicable benefits be paid on my behalf to Dr. Einig of Northwest Optometry for any furnished services. I understand that not all services and materials may be covered by my insurance or may exceed benefits or coverage. I agree to pay all payments, co-pays and deductibles at the time of service for all services and materials. I also give permission to release information to my physician, any physicians we refer you to.

I authorize Northwest Optometry to release/discuss my information with the following people regarding my care (Ex: spouse, parent, adult children)