Patient Signature / Submit Data
ABOUT YOUR INSURANCE
There are two types of health insurance that will help pay for your eye care services and optical products. You may have both types and Bakersfield Eye Care Optometric Center accepts most insurance plans in both categories: 1) Vision plans (such as VSP, EyeMed and others) and 2) Medical insurance (such as Blue Cross/Blue Shield, Medicare and others).
Vision plans only cover routine vision wellness exams, along with eyeglasses and contact lenses. Vision plans do not cover medical eye care (the diagnosis, management or treatment of eye health problems). Medical insurance must be used for medical eye care. If some fees are not paid by your insurance, we will bill you for them, such as deductibles, co-pays or non-covered services as allowed by the insurance contract.
Please provide your insurance cards to our staff member so we can make a copy. We need to have your medical insurance card or Medicare card on file in case we should need it in the future for billing your insurance.
I have read and accept these policies.
ASSIGNMENT OF BENEFITS
I hereby assign all medical/vision benefits to which I am entitled, including Medicare, private insurance, or any other health/vision plans to Bakersfield Eye Care Optometric Center. I hereby authorize said assignee to release all information necessary to secure payment. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original.
I understand that I am financially responsible for all charges not paid by my insurance, including non-covered services, such as refraction and contact lens evaluations.
AUTHORIZATION FOR THE USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
I hereby authorize the use and disclosure of individually identifiable health information relating to me, which is called Protected Health Information (PHI), under a federal privacy law. I further understand that my PHI may be used to carry out treatment, payment, or healthcare operations.
I understand that I may revoke this authorization at any time by notifying Bakersfield Eye Care Optometric Center in writing.
I have received a copy of Bakersfield Eye Care Optometric Center's Notice of Privacy Practices prior to signing this consent.
I understand I have the right to restrict how my PHI is used or disclosed by notifying Bakersfield Eye Care Optometric Center of my wishes in writing.
Patient Signature: Date: