| authorize the payment of medical benefits be made on my behalf to the Clark Eye Clinic for any services rendered me by their physicians. | further authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and/or my private insurance Carrier and its agents any information needed to determine these benefits or the benefits payable for related services. | understand that this authorization will remain in effect until | revoke its writing.
Authorization to Review/View Prescriptive Medication History
Authorization to Review/View Prescriptive Medication History
I, hereby grant permission to Dr. S. W. Clark III and Clark Eye Clinic and the personnel of the Clark Eye Clinic, P.C. to view my prescriptive medication history from external sources.
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This information will be protected and will be used to provide a complete list of medications and dosages for my medical record and to minimize possible drug interactions. This authorization will remain in effect until revoked in writing by me.
Clark Eye Clinic, PC Financial Policy
Clark Eye Clinic, PC Financial Policy
As your physician, we are Committed to providing you with the best possible medical care, To achieve this goal, we need your assistance, and your understanding of our payment policy. ° PAYMENT Mastercard, FOR SERVICE IS DUE AT THE TIME SERVICES ARE RENDERED. -We accept cash, personal checks, whichever is Visa, greater, and Discover. Returned checks are subject to a service charge of $70.00 or 5% of the face value of the check to any accounts which and you will lose your privilege to write checks in our office. There will be a $15.00 Monthly Charge added have an outstanding balance after $0 days. This does not include accounts pending insurance claims. ¢ CANCELED SHOW. APPOINTMENTS, -Patients who do not cancel appointments will be charged an office visit after the third NO : « BLUE CO-PAYMENT CROSS/BLUE AND SHIELD (INDEMNITY ONLY), STATE MERIT, SOUTHCARE PPO, AND SATILLA HEALTHNET, - insurance DEDUCTIBLE MUST BE PAID AT THE TIME OF SERVICE, Because we are under contract with these companies, we will file your insurance. ° MEDICARE, 20% of the -We are participating physicians with Medicare. We are required to collect your deductible, if due, and/or your Medicare allowable unless you have supplemental insurance for this in force. e your WORKER’S company’s COMPENSATION -We will call your employer to authorize your visit prior to your appointment. We will file with iS determined insurance. In event you fail to prosecute the claim for Worker’s Compensation for this illness or condition or it by the Worker's Compensation board that the iltness or condition is not a result of a compensable Worker's Compensation case, you agree to pay the usual and customary fees for services rendered to you in this case, ° the CHILDREN divorce decree. OF DIVORCED PARENTS, -PAYMENT IS DUE AT THE TIME OF SERVICE no matter who is responsible by order of » FINANCIAL fo your AGREEMENT, -We wit gladly discuss your proposed treatment and do our best to answer any questions relating insurance. You must realize, however, that: 2. 1. Notall Your insurance services is acontract between you, your employer, and the insurance company. We are not Party to that contract. they will are a covered benefit on all contracts. Some insurance companies arbitrarily select certain services not cover. (eg., yearly physical, routine eye exams, refraction for glasses) We insurance must emphasize company. that as your medical care providers, our relationship and concern is with you and your health, not your account after 90 days, ALL CHARGES ARE YOUR RESPONSIBILITY FROM THE DATE OF SERVICES RENDERED. Any balance on your emergencies do including those insurance has not paid, is liable to be turned over to a collection agency. We realize that for assistance arise and may affect timely payment of your account. If such extreme cases do occur, please contact us promptly in the management of your account. including If it becomes attorney’s necessary to collect any sum due through an attorney, then the patient agrees to pay all reasonable costs of collection fees, whether the suit is filed or not. ask Ifyou us. have We any are here questions about the above information or any uncertainty regarding insurance coverage, please do not hesitate to to help you
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Activity of Daily Living
Activity of Daily Living
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Have you noticed a decrease in your vision when you
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Cataract and refractive lens exchange questionnaire
Cataract and refractive lens exchange questionnaire
The term “cataract” refers to a cloudy lens inside the eye, which makes the vision blurry due to loss of focus. When a cataract is removed, an artificial lens is placed inside the eye to restore or improve the ability to focus. Along with your eye exam, this information will assist us in recommending the best options for your eyes to optimize personal lifestyle. Please fill out this form.
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How many hours per day do you
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Areas of vision, grouped by distance from near to far distance. Pick the activities you are engaged in most
12 - 20( in )
2 - 4( ft )
6 - 20( ft )
20 - 100( ft )
100+( ft )
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The Clark Eye Clinic, PC
The Clark Eye Clinic, PC
ASSIGNMENT OF HEALTH PLAN BENEFITS AND RIGHTS AS WELL AS AN APPOINTMENT AND/OR DESIGNATION AS AN ERISA/PPACA RERESENTATIVE
Payment of services and materials are payable at the time of your visit and is the patient’s or legal guardian’s responsibility. Charges unpaid or not covered by insurance should be paid within 60 days to avoid interest and/or collection fees.
Filing your insurance is a courtesy of our office. Insurance cards must be presented prior to services rendered. If your insurance card is unavailable, we will give you an itemized statement for you to file your insurance. Verification of benefits or eligibility is not an authorization or guarantee of payment. We cannot accept your insurance as payment unless you have a specific vision plan or policy for which we are providers. If we are a provider for your insurance, we will give an estimate of your co-payment(s). You will be responsible for your co-payments and any additional charges for services that are not covered by your insurance. Not all services and materials are covered. We will know the exact amount only after we bill your insurance company and they have issued an explanation of benefits with payment. Your insurance is a contract between you, your employer or agent and the insurance company. We are not a party of that contract. If you have questions regarding your insurance, please contact your insurance company.
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I understand and agree that (regardless of whatever health insurance or medical employees, benefits | have), lam ultimately responsible to pay The Clark Eye Clinic, PC., as well as all employers, representatives, and agents thereof, (hereinafter collectively referred to as (“Healthcare Provider”) the balance due on my account for any professional services rendered and for any supplies, tests, or medications provided. medical | hereby authorize payment of, and assign my rights to, any health insurance or medical or medical plan benefits directly to healthcare provider for medical/heathcare services that have or will be rendered and for any supplies, tests, or medications provided
| hereby authorize the release of any health status, conditions, symptoms, or treatment information contained in your records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid claims, or to pursue any other remedies necessary in connection with same.
| hereby assign directly to Healthcare Provider all rights to payment, benefits, and all other rights under, or pursuant to, any health plan, ERISA plan, PPACA plan, or insurance contract rights that | (or my child, Spouse, or dependent) may have under my/our applicable health plan(s) or health insurance policy(ies). This document includes, butis not limited to a designation that Healthcare Provider can act on my/our behalf, as my/our representative, ERISA representative, or PPACA representative as to claim determination, to request relevant claim or plan information from the applicable health plan or insurer, to file and pursue appeals to obtain benefits and/or payments that are due to either Healthcare Provider, myself, and/or my family members as a result of services rendered by Healthcare Provider, and to pursue any and all remedies to which I/we may be entitled, including the use of legal action against the health plan orinsurer. The assignment and/or designation will remain in effect unless revoked in writing anda photocopy or scan is to be considered as valid and enforceable as the original.
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Clark Eye Clinic Cancellation No/Show Policy
Clark Eye Clinic Cancellation No/Show Policy
Thank you for trusting your medical eyecare to Clark Eye Clinic, P.C. When you schedule an appointment with our practice, we set aside enough time to provide you with the highest quality care. Should you need to cancel or reschedule an appointment please contact our office as soon as possible, not later than 24 hours prior to your scheduled appointment. This allows us time to schedule other patients who may be waiting for an appointment. Please see our Appointment/ NO SHOW policy below:
NO SHOW 15 MINS AFTER SCHEDULED APPOINTMENT! Your appointment will be marked a NO SHOW, or we will have to reschedule.
Any established patient who fails to show for a scheduled appointment and has not contacted the office in the last 24Hrs will be marked as a No Show and charged a $25 fee.
Any new patient who fails to show for a scheduled appointment without at least a 24hrs notice will be charged a $25 fee
The fee is to the patient, not the insurance company and is due at the time of the next appointment
As acourtesy, our office will attempt to make reminder calls for appointments. Many people do not have voice mail set up on their phone or the voice mail box is full. Even if you do not receive a reminder call or message, the above policy remains in full effect. We understand there may be times when an unforeseen emergency occurs, and you may not be able to keep your scheduled appointment. If you should experience extenuating circumstances, please contact our Clinic Administrator, who may be able to waive the NO SHOW fee. You may contact the Clark Eye Clinic P.C. during our normal business hours 9:30 A.M. to 5:30 P.M., Monday through Friday. After business hours you will reach our answering services that can relay any messages to use the next business day.
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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
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