Intake Online Form

PLEASE READ CAREFULLY

ADDITIONAL TESTS – PLEASE READ CAREFULLY

OFFICE POLICY

• All visits to the office are due and payable at the time of service
• All fees are for professional services and therefore are non-refundable
• Contact lens exam fees include up to 2 follow up visits within 30 days from the date of initial examination

1. HIPAA NOTICE OF PRIVACY PRACTICES:  I acknowledge that I have received the Notice of Privacy Practices issued by Riz Eye Care that was effective April 1, 2005. for more information visit www.rizeye.com

2. RELEASE OF INFORMATION: Riz Eye Care may disclose all or part of my medical record and/or financial ledger, including information regarding alcohol or drug abuse, psychiatric illness, communicable disease, or HIV, to any person or corporation (1) which is or may be liable or under contract to Riz Eye Care for reimbursement for services rendered, and (2) any health care provider for continued patient care.  A copy of this authorization may be used in place of original.

3. NON-COVERED SERVICES:  I understand that Riz Eye Care contracts with health care service plans (i.e., HMO’s, PPO’s) relate only to items and services which are “covered” by health care service plans.  Accordingly, the undersigned accepts full financial responsibility for all items or services, which are determined by the health care, service plans not to be covered, including refraction fee (which is not covered by Medicare).  I agree to cooperate with Riz Eye Care to obtain necessary health care service plan authorizations.

4. FINANCIAL AGREEMENT: I agree that in return for the services provided to me by Riz Eye Care, I will pay my account at the time service is rendered or will make financial arrangements satisfactory to Riz Eye Care for payment.  IF my account is sent to an agency for collection, I agree to pay collection expenses and reasonable attorney’s fees as established by the court and not by a jury in any court action.  I understand and agree that if my account is delinquent, I may be charged interest at the legal rate.  Any benefits of any type under any policy of insurance are hereby assigned to Riz Eye Care.  If co-payments and /or deductibles are designated by my insurance company or health plan, I agree to pay them to Riz Eye Care.  However, I understand that I am primarily responsible for the payment of my bill.

5. MEDICARE: I request that payment of authorized Medicare benefits be made on my behalf to Riz Eye Care, for services furnished to me by Riz Eye Care. I authorize any holder of medical information about me to release the centers for Medicare and Medicaid services and its agents any information needed to determine these benefits or the benefits payable for related services.  I understand my signature requests that payment be made and authorized release of medical information necessary to pay the claim.  If other health insurance is indicated in Item 9 of the HCFS 1500 form or elsewhere on other approved claim forms, my signature authorized releasing the information to the insurer or agency shown.  Riz Eye Care accepts the charge determination of the Medicare carrier as the full charge, and I am responsible only for the deductible, coinsurance, and non-covered services.  Coinsurance and deductible are based upon the charge determination of the Medicare carrier.

6. MEDIGAP: I understand that if a Medigap policy or other health insurance is indicated in Item 9 of the HCFA 1500 form or elsewhere on other approved claim forms, my signature authorizes release of the information to the insurance or agency shown. I request that payment of authorized secondary insurance benefits be made on my behalf to Riz Eye Care, if possible, or otherwise to me.

7. OTHER INSURANCE: I authorize payment of my medical and surgical insurance benefits to Riz Eye Care. I understand that I am financially responsible for any charges whether or not paid by said insurance.  If co-payments and/or deductibles are designated by my insurance company or health plan, I agree to pay them to Riz Eye Care.

To avoid misunderstanding and confusion about our professional fees for Vision Care vs. Medical Care, please read and sign the following:

• Systemic health problems (diabetes, high blood pressure, thyroid, etc.)
• An eye disease (cataracts, glaucoma, diabetic retinopathy, allergic conjunctivitis, ocular surface disease, etc.)
• A medical condition that requires taking a high-risk medication (plaquenil, etc.).

RIZ EYE CARE CONTACT POLICY

1. The contact lenses are fitting and moving well
2. The prescription is providing the best possible vision
3. The eyes are remaining healthy
4. There are no problems with insertion or removal
5. The patient understands and complies with the recommended wearing schedule

• The contact lens fitting
• A visit is required
• Training sessions
• 2 Follow-up visits within 30 days- After 1 month the fitting fee and a Refraction fee will be applied if visit is required.
• Diagnostic lenses (one trial pair)

• Contact lenses (Costs will vary depending on type of lens prescribed)
• The comprehensive eye exam
• Medical visits not directly related to contact lens wear

For more information visit www.rizeye.com