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Patient Registration Form

Demographics

Race

Ethnicity

Guardian Information (if patient is under 18 years of age)

Insurance Information

Emergency Contact

Patient Registration Form

Family History: Please check and list- Father, Mother, Brother, or Sister

Medication Allergies:

Environmental Allergies:

General Medical History

Any other Eye Condtions:

Surgeries:

Current Medications:

Past Medical History and Review of Systems

Do you currently have or have you ever had any of the following:

Constitutional

ENT

Neuro

Psych

Cardiovascular

Respiratory

GI

GU

Musculoskeletal

Integumentary

Endocrine

Hem/Lymphatic

Allergy/Immune

Please list any other past medical conditions:

Please list any other current medical conditions:

Policy and Privacy Forms

HIPAA PRIVACY AUTHORIZATION

Authorization For Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act- 45 CFR Parts 160 and 164)

I hereby authorize Eye Center of Virginia to use and/or disclose my protected health information and record covering all past, present, and future periods for:

Medical treatment or consultation, billing or claims payment, or other purposes as I may direct. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. You have my permission to disclose protected health information to the following people (such as spouse, parent, child, etc) and I may revoke my permission at any time in writing:

MEDICARE LIFETIME AUTHORIZATION (only applicable if you have Medicare)

I request the payment of authorized Medicare benefits to be made either to me or on my behalf to Eye Center of Virginia for any services furnished to me by any provider employed by Eye Center of Virginia. I authorize any holder of medical information about me to release to HCFA and its agents any information needed to determine these benefits or the benefits payable for related services.

FINANCIAL POLICY

With your permission we keep your signature on file to file and process insurance claims. Payment is required at the time services are rendered.

While we assist you in filing your insurance claims, your insurance is an agreement between your insurance and you and we cannot guarantee payment for any services. We do our best to verify your insurance and eligibility. Ultimately, it is your responsibility to contact your insurance carrier by calling the number on the back of your card and verifying your coverage, limitations, and estimated out of pocket costs. Sometimes your insurance requires a referral to us and we make every effort to recognize those plans before you are seen but it is ultimately your responsibility to obtain any authorization or referral ahead of time if one is needed. If these are not obtained you will be responsible for all charges if they are denied.

All services, including but not limited to, co-payments, deductibles, co-insurance, and non-covered services are your responsibility. Co-payments are due at the time of your appointment and contact lens orders must be paid in full at the time the order is placed. If you are paying by check and it is returned for any reason there is a $35.00 returned check fee and you authorize us to represent the check to your bank for collection, which may result in an additional fee.

We will file your claims to your primary insurance. It is your responsibility to notify them of your secondary insurance since most automatically forward your claim. We can provide a copy of your charges so you can submit to secondary and tertiary policies if needed. If you receive a service that is a non-covered charge by your insurance you are responsible for the charge.

Patients arriving unable to make payment or without insurance cards, failing to notify us 2 business days prior to your appointment to cancel/reschedule, or no-shows will be charged a $30 fee.

VISION PLANS, MEDICAL INSURANCE, REFRACTION, AND CONTACT LENS EXAMS

There are 2 types of insurances that help you pay for eye care services and products -Vision Plans such as Eyemed, VSP, Blueview Vision, and MetLife -Medical Insurance such as Anthem, Medicare, Optima, Cigna, Aetna, UHC, Humana, and others.

Vision Plans only cover the routine exam and refraction (the testing portion that provides your glasses prescription) and may cover the contact lens exam, glasses, and contacts- they do not cover medical eye care.

Medical Insurance must be used if we are diagnosing, testing, or treating a medical condition and most medical insurances DO NOT cover the refraction, contact lens exams, or materials.

If you do not have a Vision Plan that covers the refraction and your Medical Insurance does not cover it you will be responsible for the cost- $65. Examples of Medical Insurances that do not cover it include Medicare, some Anthem plans, Humana, and most Medicare Supplement/Medigap insurance.

Contact Lens Exams are required each year to ensure the health of the fit and update the prescription. Medical Insurance does not cover this and some Vision Plans cover it in full, a portion, or not at all- all Vision Plans are different. If you do not have a Vision Plan or you do not have coverage the cost can range from $65 to $200 depending on if you are a new or established patient and what type of fit you are. RGP or custom/specialty Contact Lens Exams may cost more due to the customization and time required to fit the lenses.

Please contact your Medical Insurance to see if they provide a Vision Plan. We will attempt to find coverage for you with the plans we accept. If you have any questions about your coverage please ask us! We also offer an in-house discounted exam if you do not have a Vision Plan!

I have read and understand these policies

Exclusive Offer

New patients receive 20% OFF first Optical Purchase. Valid on complete frame and prescription lens purchase only. Not to be combined with insurance or any other discount or promotion.

 

Apply Today!

THIS ---->https://eyecenterofvirginia.com/patient-registration-form.html

Office Hours

DayMorningAfternoon
Monday8:00am5:00pm
Tuesday8:00am7:00pm
Wednesday8:00am5:00pm
Thursday8:00am7:00pm
Friday8:00am3:00pm
Saturday8:00am*12:00pm*
SundayClosedClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8:00am 8:00am 8:00am 8:00am 8:00am 8:00am* Closed
5:00pm 7:00pm 5:00pm 7:00pm 3:00pm 12:00pm* Closed

Closed 12 to 1 for Lunch Every Day.

*For Saturdays,

Open 2nd Saturday of every month only.*

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