Patient Registration And History Form Family Eye Health Associate (Page 3 of 7) in pdf

2374 Post Road, Suite 104

Warwick, Rhode Island 02886

Ph (401) 921-0098 ~ Fax (401) 921-0073

Date_________________

PRIVACY PRACTICES ACKNOWLEDGEMENT

I have received the notice of Privacy Practices and have been provided an opportunity to review it.

Name__________________________________________

Birthdate_________________

Signature of patient/parent/guardian/personal representative:_____________________________________

INSURANCE INFORMATION

There are two types of health insurance that will help pay for your eye care services and optical products. You may

have both types and Family Eye Health Associates accepts most insurance plans in both categories: 1) Vision plans

(such as VSP, EyeMed and others) and 2) Medical insurance (such as Blue Cross/Blue Shield, Medicare and

others).

· Vision plans only cover routine vision wellness exams, along with eyeglasses and contact lenses. Vision plans do

not cover medical eye care (the diagnosis, management or treatment of eye health problems).

· Medical insurance must be used for medical eye care.

· If you have both types of insurance plans it may be necessary for us to bill some services to one plan and some

services to the other. We will follow a procedure called coordination of benefits to do this properly and to minimize

your out-of-pocket expense.

· If some fees are not paid by your insurance, we will bill you for them, such as deductibles, co-pays or non-covered

services as allowed by the insurance contract.

Please provide your insurance cards to our staff member so we can make a copy. We need to have your medical

insurance card or Medicare card on file in case we should need it in the future for billing your insurance.

I have read and accept the policies stated above. I certify that I assign directly to Family Eye Health Associates,

LLC all insurance benefits, if any, otherwise payable to me for services rendered.

I understand that I am

financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature

on all insurance submissions. Family Eye Health Associates, LLC may use my health care information and may

disclose such information to Medicare or other insurance company(ies) and their agents for the purpose of obtaining

payment for services and determining insurance benefits or the benefits payable for related services.

Signature of patient/parent/guardian/personal representative:_____________________________________

Printed name of patient/parent/guardian/personal representative:__________________________________

Relationship to patient_______________________________________

Patient Registration And History Form Family Eye Health Associate Page 3