New Patients Form

First Name:

M.I.:

Last Name:

SS#:

Sex: Male Female

Date of Birth:

Marital status: Married Single

Other Mailing address:

E-mail:

City:

State:

Zip code:

Home phone:

Alternate phone:

Employer:

Work phone:

Emergency Contact:

Name:

Phone:

Relationship:

Pharmacy Name:

Location:

Are you interested in Latisse today? Yes No

Are you interested in BOTOX today? Yes No

I was referred to Hill Country Eye Center by:

Dr:

Previous Patient:

Internet (site?):

Family/Friend (name?):

Advertisement (where?):

Other:

INSURANCE INFORMATION

If you would like us to file claims with insurance, please fill out the section below. You may be required to obtain a referral (and keep it up to date) from your primary care physician before insurance will pay for an exam with Dr. Restivo, Dr. Robertson or Dr. Cottle. While it is the responsibility of the patient to obtain referral authorization before their visit, our office will do everything possible to obtain the referral for you if you haven’t done so already. Per the contract between you and your insurance company, you will be responsible for any charges if a referral cannot be obtained and your insurance company denies payment.

Primary Insurance

HMO

PPO

Other:

Subscriber’s Name

Subscriber’s DOB

Subscriber’s SS #

Secondary Insurance

HMO

PPO

Other:

Subscriber’s Name

Subscriber’s DOB

Subscriber’s SS #

FINANCIAL POLICY

Hill Country Eye Center will file claims to your insurance, when applicable, as a courtesy to you. It is important for you to understand that the contract exists between you and your insurance carrier. Hill Country Eye Center will attempt to verify your benefits and coverage prior to your visit, however, there is no guarantee that your insurance company will pay for services rendered by our facility. We require that co-pays, applicable deductibles and coinsurance be paid at the time of service. We will attempt to provide an estimate of the charges at time of service. If a balance is incurred we will send you a statement for any outstanding balance.

Private pay patients are expected to pay in full at the time of service unless prior arrangements have been made. You will receive a prompt pay discount on services provided when paid at time of service.

Refraction is a test used to determine what prescription lenses will best correct a patient’s vision, resulting in the patient’s glasses prescription. Many insurance companies do not cover the cost of refraction, currently set at $70, and patients will be billed this amount upon denial from their insurance company. MEDICARE does not ever pay for refractions. Patients with MEDICARE will be required to pay this fee at the time of service.

Routine vision may or may not be covered by your medical insurance plan. We will attempt to verify coverage for routine eye exams before your visit. If there is no medical diagnosis found during your exam, and your insurance company does not provide routine coverage, you will be responsible for the charges upon denial from your insurance company.

Hill Country Eye Center maintains a returned check fee policy of $30. Any patient with two returned checks will no longer be able to pay by check. Additionally, we also may charge a no show fee of $25.00 for each appointment without a 24 hour notice of cancellation.

ASSIGNMENT OF BENEFITS

I understand that I am fully financially responsible for any and all charges incurred during the course of authorized treatment. I further understand that all applicable fees are due on the date that services are provided and agree to pay such charges in full. I hereby assign all medical and surgical benefits to Hill Country Eye Center, including major medical benefits, to which I am entitled. I authorize and direct my insurance carrier(s) to issue payment checks to Hill Country Eye Center for medical services rendered to myself or minor children. I understand that I am responsible for any amount not covered by my insurance benefits.

AUTHORIZATION TO RELEASE INFORMATION

I authorize Hill Country Eye Center to release any information necessary to insurance carriers regarding my treatments, process insurance claims generated in the course of examination, and allow a photocopy of my signature to be used to process insurance claims for the period of my lifetime. I authorize Hill Country Eye Center to disclose protected health information, including lab results and diagnoses, in messages left on my voicemail at the following number (), and to the following person(s)

ACKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES

I have reviewed Hill Country Eye Center’s Notice of Privacy Practices provided behind this paperwork, which describe how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document if I ask for one.

Patient Signature: ________________________________________ Date _______________

Clinic Representative: ______________________________________ Date _______________

CONTACT LENS POLICY

If you are interested in contact lenses, please read and sign below. IF NOT, please disregard.

Contact lens evaluations and lenses are not included in the cost of a complete eye exam. Payment for contact lens evaluations is due at the time of service. Most insurance companies do not cover contact lens evaluation. The patient is responsible for payment in full for this charge and may file their payment to their insurance if they choose to. Payment for contact lenses is due at the time of disbursement.

Contact lens evaluations will be charged as follows and is good for 90 days from the initial fitting: New contact lens patients $100 Existing lens wearers needing an evaluation with no change to their prescription $40 Existing lens wearers needing a power adjustment or a new brand or type of lenses $60 Existing Gas Permeable lens wearers $60 Bi-focal contact lens fittings $150 Specialized contact lens evaluations – charged at the physician’s discretion

Hill Country Eye Center offers patients the convenience of ordering contacts through our office and our website. There are discounts associated with ordering a 1-year supply on our website and having them shipped directly to your home, rather than having our office order them and picking them up from our office. Please consult Jodi or Mindy if you have any additional questions regarding contact lenses or fittings.

Patient Signature: ________________________________________ Date _______________

Clinic Representative: ______________________________________ Date _______________

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