Policies and Consents
Thank you for choosing Woodlands Eye Associates for your eye health needs.
We would like to take this moment to discuss our financial policies and consents.
HIPAA Consent to Use or Disclose Health Information
For Treatment, Payment, and Healthcare Operations
In the course of providing
health care to you, we may need to create, receive, and/or store health information
potentially identifies you. It is often necessary to use and disclose this health information
in order to treat you, to obtain payment for services, and to conduct healthcare
operations involving our office. A comprehensive "Notice of Privacy Practices" is
available from our office that describes in detail the use and disclosure of such health
information. You are free to refer to this notice at any time before you sign this consent
document. As described in our "Notice of Privacy Practices" the use and disclosure of
your health information is necessary for you to receive ongoing care from this office or
in conjunction with other health professionals. Our "Notice of Privacy Practices" will be
updated when our privacy practices changes. Whenever our practices change you may
obtain an updated copy from our offices, or from our website at
. When you sign this consent form, you agree to the use and
disclosure of your health information to treat you, to obtain payment for our services,
and to perform healthcare operations.
I hereby consent to the release of medical information (self,
child/dependent, or family member) to the insurance companies responsible for my
care. I understand that while my medical records are confidential, information within
these records may be required by my insurance company in order to facilitate care, and
will only be released at their request. I understand that by signing this consent form, I
am allowing my medical information to be released upon my insurance company's
request, for the purpose of healthcare operations (including but not limited to, provider
review function, claims payments, and quality assessment).
- Woodlands Eye Associates is in network as preferred providers
with many medical health plans and vision discount plans. Woodlands Eye Associates
will make every effort to verify coverage and benefits prior to your visit with the
physician. If we are unable to verify benefits, we will ask you to pay in full or
reschedule your visit until the verification can be obtained
. This verification will be
used to estimate your financial responsibility; however, this verification is not a
guarantee by your health plan of coverage or payment. If your health plan denies any
part (or the entirety of your claim), you agree that you are financially responsible for the
Medical Insurance - Medicare, United Health Care, Blue Cross, Aetna, Cigna, etc.
We bill medical insurance when you present a medical related complaint such as: itch,
burn, dryness, redness, eye pain, etc. that may or may not require treatment and
monitoring. We will also bill your medical insurance carrier for medical
diagnosis/findings such as Diabetes, Glaucoma, Cataracts, Floaters, Macular
Degeneration, etc. HMO Policies:
We will help assist you in obtaining a referral
authorization from your Primary Care Physician (PCP)
by faxing the detailed
information required for your visit. If we cannot obtain an authorization/referral for your
visit, you will be billed for the services rendered. Reminder:
If you have not established
care with your designated Primary Care Physician (PCP)
for your HMO medical
insurance, you may be required to schedule an appointment with your Primary Care
Physician (PCP) prior to authorizing referrals. Primary Care Physicians (PCP) may have
their own policies in place to issue referrals for services.
If you present with both a vision complaint and a medical complaint, we will
bill to the appropriate insurance as indicated in your insurance by-laws.
- We are Medicare participating providers; therefore, we will bill
Medicare directly. However, as with any insurance carrier, you will be responsible at the
time of services for payment of:
The annual deductibles
Charges for non-covered services: Example: $39.00 Refraction fee (may not be
covered by Medicare supplement plan and/or vision discount plan).
A refraction is required to determine your best corrected vision. We will conduct
refraction whether you wear glasses or not.
You will also be asked to sign an Advanced Beneficiary Notice (ABN) form in the
event a service is provided, which we know is not covered by Medicare or your
Important: Please let us know if you signed up for a Medicare Advantage Plan.
Traditional Medicare and Medicare Advantage Plans are not the same. If you
signed up with a Medicare Advantage Plan, you no longer have traditional
Vision/Routine Insurance - VSP, Superior, Eyemed, Spectera, etc.
plans are billed for routine eye exams, glasses or contacts lenses. They do not cover
medical related complaints or conditions. Most vision discount plans require an
authorization before your services are rendered. If we cannot obtain an authorization,
you will be responsible to pay for both professional services as well as eye wear
Private Pay Patients
- We will provide you with itemized receipts for all transactions if
you chose to file your own claim to your insurance carrier.
Contact Lens Policy
- (only applicable for patients desiring contact lenses) All contact
lenses are "medical devices" according to federal law, and as such, require a proper
fitting (in addition to the routine examination) to ensure ocular health. For patients who
would like to be fit with contact lenses, the doctor performs a comprehensive eye exam
to check the overall health of your eyes, as well as additional testing to assess the fit,
prescription, and type of contact lens that best suits your eyes. The contact lens fitting
fee ranges from $69.00 on up depending on the complexity of your prescription
This fee includes trial contact lenses for the purpose of prescription changes
and follow-up visit(s) when needed. Fees that are paid for examinations, contact lens
evaluation/fitting, and progress checks for contacts lenses are non-refundable. If you
are brand new to contacts, a one-time fee of $49.00 is charged for a Contact Lens
Training in our office.
A period of 60 days is allotted for all contact lens follow-up
visits. A separate charge for any additional visits past the 60-day time frame may apply.
Your prescription will be finalized once the doctor has determined an appropriate and
healthy lens that you are satisfied with, and you have expressed to us that you would
like to proceed with an order. Contact Lens Exams are required annually along with
a Comprehensive Eye Exam. A contact lens prescription is valid for 1 year.
- Payment of copays, deductibles, coinsurance, out of pocket or non-covered
services are due upon check out. We always obtain the most accurate amounts due
from your insurance carrier. We will issue a refund or bill your account once we receive
your explanation of benefits (EOB) from your insurance carrier. You will receive a
detailed statement in the mail regarding your portion of the bill.
- For your convenience we accept cash, pre-printed NON temporary
checks, Visa, MasterCard, American Express, Care Credit, Discover, Flex
Spending/HSA accounts and online bill pay as a form of payment.
- Please be aware that certain office products, procedures or services
may not be covered, or may be considered not medically necessary by your health plan.
You are responsible for payment of these services. Such procedures and products
include but are not limited to: contact lens fittings, specialty
contact lenses, specialty eye glass lenses and designer frames, glaucoma scans, visual fields or other medically
necessary testing. You will be billed if we obtain a denial from your insurance company
and/or we have not received payment from the insurance company within 60 days of
our filing your claim.
Past Due Accounts
- If your account becomes past due, we will take necessary steps
to collect this debt. We are here to help.
We encourage you to contact our insurance specialists to discuss your bill as needed.
Medical Plaza Office Location: Christina
Office Phone: 281-367-2020
Panther Creek Office Location: Mollie
Office Phone: 281-367-5335
Our insurance specialists are available Monday-Friday 8:30-5:00pm. If they are
unavailable to take your call, please leave a detailed message and they will
return your call within the next business day.
- There will be a $25 service fee charged to your account if your check is
returned by your bank for any reason. Upon notification from our office of your returned
check, payment of the entire balance is due immediately. We will accept payment in the
form of credit card, cash, or money order.
Photo & Social Media
Woodlands Eye Associates uses a variety of resources
to publicize events, products, and services. Should you object
to a photograph or other
electronic image of you or your child on social media, the company website, marketing
brochures, publications, newsletters, or other media coverage prepared for use both
inside and/or outside Woodlands Eye Associates, please notify our office. We would
love for you to share your experiences at Woodlands Eye Associates with your family
*I have read and agree to the policies and consents outlined above.