Adult new patient form
Relationship to person responsible for payment
Name and phone number of emergency contact not living with you:
If patient is a child, name and contact information of parent or guardian living with child:
Your signature below authorizes us to release information and receive payment from your insurance company for those services received from the physician and the assisting physician.
This Authorization Remains in Effect Unless Revoked by me in Writing:
- I hereby authorize EYE CONSULTANTS OF ATLANTA, PC, hereinafter referred to as “ECA”, to provide information concerning any treatment rendered to me, or to any member of my family, to: a) my insurance carrier(s); b) any physician who referred me to “ECA”; and c) any medical practitioner “ECA” physicians may refer me (them) to for further medical or therapy treatment.
- I authorize the release of any medical information, including confidential information related to psychiatric care, drug, and alcohol abuse, and HIV / AIDS treatments, necessary to process insurance claims or required for utilization review or quality assurance activities.
- I further authorize “ECA” to utilize any modern form of transferring this documentation – including, but not limited to, the US Mail, Federal Express, telefacimilie (faxes), couriers or other similar methods – to its requested destination.
- I hereby assign to “ECA” all applicable payments to be received from my insurance carrier(s) for medical services rendered. I further authorize the transfer of funds, for credit balances on my accounts, between “ECA” and Piedmont Eye, LLC, for any and all outstanding account balances that may reside in either entity, and I understand that any remaining credit balance shall be refunded directly to me.
- I hereby agree that I am personally responsible for ensuring that all charges for services rendered are paid by either myself or my insurance carrier(s).
Patient's Signature (Parent or Guardian, if minor)
PATIENTS UNDER 18 YEARS OF AGE MUST BE ACCOMPANIED BY A PARENT OR GUARDIAN. THIS IS REQUIRED BY LAW AND SERVES TO PROTECT YOU AND YOUR CHILD.
I request that payment of authorized Medicare benefits be made, on my behalf, to “ECA” for any services furnished to me by those physicians. I authorize any holder of medical information to release to the Health Care Financing Administration, i.e., Medicare, and its agents, any information needed to determine those benefits or the benefits payable for related services.
EYE CONSULTANTS OF ATLANTA FINANCIAL POLICY LETTER
We are committed to meeting your health care needs. Our goal is to keep your insurance or other financial arrangements as simple as possible. In order to accomplish this in a cost-effective manner, we ask that you adhere to the following guidelines:
(PLEASE INITIAL THE FOLLOWING)
I acknowledge that I understand and accept this financial policy.
- You are ultimately responsible for payment of charges for services you receive from our office. Refractions (the part of the examination to test your vision for glasses) and routine eye examinations usually are not covered services on medical insurance plans. Therefore, payment is expected at the time of service.
- It is your responsibility to provide us with your current address, telephone number, email address and insurance information at each visit.
- It is your responsibility to contact your insurance carrier to confirm that the doctor you are seeing is a participant of your plan.
If you see a doctor that is not currently on your plan, you will be responsible for payment in full.
- All co-payments are due at the time of service. Up to a $75 service fee will be charged for failure to pay the co-payment at the time of service.
- If you are unable to keep your scheduled appointment and do not call us to cancel or reschedule the appointment, there will be a $50 charge. We must receive notification of this change no later than 24 hours from the scheduled appointment.
- Medicare Recipients: We are a participating Medicare practice and thus, will file your Medicare claim. If you have supplemental coverage, we will also file only one supplemental plan. During the month of January, it is our policy to collect in full your Medicare deductible and the 20% co-payment at the time of service. This holds true regardless of the availability of supplemental coverage or payment of your deductible to non-ECA physicians or providers.
- If you are experiencing personal circumstances that will make payment of our charges difficult for you, please contact one of our Patient Account Representatives at 404-351- 2220.
- Medicare does not cover the refraction (the part of the examination to test your vision for glasses). Therefore, the fee of $53 is your responsibility in addition to the 20% co-payment.
- We will mail you a monthly statement for any outstanding balances. If the claim has not been paid by our insurance carrier within 30 days of the date of service, please contact your carrier and assist us in getting your claim paid.
(For your convenience, we accept cash, personal checks, Visa, MasterCard, American Express and Discover).
The REFRACTION is the part of an eye examination to determine the prescription for corrective lenses. Without the refraction, we cannot provide a prescription for corrective lenses.
Historically, most insurance plans do not pay for this portion of an examination. If your plan does not pay for glasses or contact lenses, they most likely will not pay for the refraction. We do not include this procedure in our routine examination charge.
You may elect not to have the refraction done in this office, however we will not be able to provide a prescription for glasses without it.
If you do have a refraction done in our office, there will be a $53.00 charge at the time of service, in addition to any co-payment or other non-covered fees. We will provide you with a receipt that you may file with your insurance company for reimbursement if your insurance plan considers this a covered expense.
We appreciate your understanding in this matter. Refraction is a very important part of an examination if you require corrective lenses. We truly wish that all insurance plans considered this a covered expense.
Notice of Privacy Practices Acknowledgment
Patient Acknowledgment Form
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. By signing below, you acknowledge that you have received a copy of the Notice of Privacy Practices.
As stated in our Notice of Privacy Practices, we will use and disclose your health information for treatment, payment and health care operations, as well as other purposes stated in the Notice. By consenting to treatment and accepting financial responsibility for your treatment, you agree and acknowledge that from time to time we will communicate with you about your treatment, payment and related issues using the means of communication that you have furnished to us, including your e-mail and cell phone number. We may call and/or text your cell number or e-mail you with treatment and related information, such as appointment confirmations and reminders, annual visits and wellness check-ups, pre-operative instructions, prescription notifications, payment reminders, to recommend treatment options or alternatives or follow-up items or services. In addition, we may share with you certain health-related items or services that may be of interest to you. It is the policy of Eye Consultants of Atlanta that you may opt-out of e-mail or cell/text communications at any time.
Requests for Confidential Communication of Protected Health Information:
I, request that Eye Consultants of Atlanta, P.C. communicate with me, or the designated individual(s) identified above, concerning my medical information by the following method. Alternative communication methods include, email, cell phone (or other phone number I designate) or texting.:
Alternate communication method example: Answering machine, pager, e-mail, text message and anyone who accompanies me in the exam room.