After completing all the forms, please submit your data using the button on the "Submit Form" tab. Thank you!
If you are filling paper work on the portal, please upload picture of DL/insurance cards
Medical History
Please choose from the menu options or if your option is not listed, please describe in the text box at the bottom of the page.
Please check all that apply:
If none, please type "None" into Medication 1
PRIVACY and FINANCIAL
Federal law requires that Southwest Vision make every effort to inform you
of your rights related to your personal health information. If you would like to review our Notice of Privacy Practices,
please click here.
By entering your name below as a digital signature, you acknowledge that you understand Southwest Vision's
Notice of Privacy Practice and agree to continue your care with Southwest Vision under said terms. You agree that you are signing it voluntarily.
Please type your name into the signature fields to sign.
HIPAA requires a patient's prior authorization in order to release medical information to another person.
This includes, but is not limited to, medical records, eyeglasses or contact lens prescriptions, receipts or any other documents with personal information.
Please list any person or persons you wish to allow access to your medical records and personal information:
In today's financial climate we understand that patients must be efficient with their money and that you, as a patient and consumer, have options in the Optical Community. In order to help keep your costs down, we are making a concerted effort to run as financially efficient as we possibly can. In order to do this, we
strictly abide by the following policies:
1. Payment is due at the time services are rendered. Our staff will provide you with information that is as accurate as is available from your insurance company regarding your copay, deductibles and coinsurance amounts. Balances that are residual after filing with your insurance company will be expected to be paid in full prior to your next scheduled visit or statement date (whichever is sooner). WE HIGHLY RECOMMEND THAT YOU READ YOUR INSURANCE BENEFIT BOOKLET OR CALL YOUR INSURANCE COMPANY TO REQUEST BENEFIT DESCRIPTIONS FOR A SPECIALIST OFFICE. If you are unable to pay at the time of service, your appointment will be rescheduled.
2. REFERRALS: Some insurance plans require a referral from your primary care physician prior to seeing
a specialist. Although we will assist you in obtaining a referral, it is ultimately your responsibility to make sure such a referral has been obtained prior to receiving care from Southwest Vision. Failure in having an effective referral may result in denial of payment from your insurance company, leaving you responsible for any and all services provided.
3. FEES
- Returned Check: $35
- Medication Prior Authorization: $50
- Missed Appointment: $35
- Late Payment: 1.5% additional charge of balance after 2 failed charge attempts
4. Should you default on your balance, Southwest Vision reserves the right to discharge you as a patient, not accept new diagnoses, and collect a $125 collection fee prior to re-establishing you as a patient.
5. You will be responsible for promptly responding to your insurance company to provide any additional information they may request regarding your treatment. Failure to respond in a timely manner may result in your account becoming due immediately and payable in full.
6. MINORS: Individuals under the age of 18 will be rescheduled should they not be accompanied by a parent of legal guardian or have a written permission form signed by a parent or legal guardian.
7. ASSIGNMENT OF BENEFITS: By signing below, I authorize my insurance benefits to be paid directly to Southwest Vision and acknowledge that I am financially responsible for any balance(s). I authorize Southwest Vision or the insurance company to release any information required to process my claims.
Furthermore, I acknowledge that I have read and agree to all of the above listed terms.
Please type your name into the signature fields to sign.
Although not required to schedule your appointment, we request a credit card authorization to keep on file as a convenient method of payment for that portion of services and/or products your insurance does not cover or for amounts filed toward your deductible.
Balances due as a result of your insurance applying your deductible will be collected only after the claim has been processed by your insurer.
This information is kept confidential and secure at all times. Prior to processing a payment, we will attempt to contact you with the specific amount to be charged.
By filling out the information below, you authorize Southwest Vision to charge the portion of your balance that is your financial responsibility to the following credit card:
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