Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.
This form contains confidential information and is delivered to your doctor through a secure Internet connection.
About your Insurance
There are two types of insurance that will help pay for your eye exam services and optical products. You may have both types and ParkRidge Vision Specialists 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, Cigna 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 you have both types of insurance plans it may be necessary for us to bill some services to one plan and some services to the other. We will follow a procedure called coordination of benefits to do this properly and to minimize your out of pocket expense. Please ask our staff if you have any questions.
We will bill your insurance company as a courtesy. Insurance is a contract between you and your insurance company. We are NOT at party to this contract. We may provide an estimate of what your insurance company may pay; however, the insurance company makes final determination of your eligibility on benefits only after a claim has been submitted for processing. Benefits quoted to our office by insurance companies are NOT a guarantee of payment. ParkRidge Vision cannot guarantee or promise that services provided at the time of the visit will be covered by the patient’s insurance plan or covered under one copayment.
- I (patient or responsible party) will disclose all insurance information including primary and secondary insurance, as well as, any changes of insurance information. Failure to provide complete insurance information may result in my responsibility to pay the entire bill.
- I agree to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance.
- I am responsible for any co-payments, co-insurances, deductibles, plus any balance due on non-covered services not paid by my insurance within the state’s required time limitation for paying healthcare claims. The copay requirement can not be waived by our practice, as it is a requirement placed on you by your insurance carrier. All co-payments are due at the time services are rendered.
As a provider, we may bill Medicare for medical office visits. The patient is responsible for the $40.00 refraction fee, which is NOT reimbursable by Medicare.
Having more than one insurer DOES NOT mean that your services will be covered 100%. Secondary insurers will only pay a portion of what your primary pays. We only bill secondary insurance companies for patients with Medicare. All others must be submitted by the patient for reimbursement after paying PRVS in full for outstanding balances.
If I miss or cancel an appointment without a 24 hour notice, I may be charged a fee of $50.00.
I will be responsible for a fee of $35.00 for a returned check. This will be applied to my account in addition to the insufficient funds amount.
- The adult (parent, guardian) accompanying a minor is responsible for the co-payment at the time of service. (A divorce decree does not determine which party PRVS will bill for medical services on the patient’s account. Divorce decrees are only binding upon the two parties who made the agreement.)
- The parent, guardian accompanying the child(ren) on the first appointment will be considered the guarantor (responsible party) on the patient’s account. The guarantor is responsible for out of pocket expenses including but not limited to co-payments, co-insurances, deductibles and any non-covered services.
All Warranty work will be subject to a $20.00 shipping and handling fee.
The Guarantor (responsible party) is responsible for all out of pocket fees. Past due accounts greater than 90 days are in default. Upon default I agree, subject to state and federal law to pay all costs of collection including interest, attorney fees, collection fees and applicable late fees.
I, the undersigned, hereby consent to and authorize all diagnostic and therapeutic treatment performed at ParkRidge Vision Specialists, (“PRVS”) considered necessary or advisable by the attending doctor.
I authorize PRVS to file any claims for payment of patient bills and assign all rights and benefits to PRVS as appropriate. Except as prohibited by any agreement between my insurance company and PRVS or by state or federal law, I agree to be responsible for co-payments, deductibles, or other charges for medical services and materials not covered or paid by insurance or third party payors. I hereby authorize said assignees to release appropriate information to secure payment.