Patient Intake Online form

HIPAA - Patient Consent for use and disclosure of protected health information I hereby give my consent for Wind City Eye Care to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Wind City Eye Care's Notice of Privacy Practices provides a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent.Wind City Eye Care reserves the right to revise its Notice of Privacy Practices at anytime. With this consent, Wind City Eye Care can call me at home or other alternate locations and leave a message or voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, obtaining insurance information, billing and any calls pertaining to my clinical care. With this consent , Wind City Eye Care may mail to my home or other alternative locations any items that assist the practice in carrying out TPO, such as appointment reminder cards, statements and/or insurance information. By signing this form, I am consenting to V EYE P the use and disclose of my PHI to carry out TPO. My signature below signifies my understanding and willingness to comply with the above policies.

When provided the necessary insurance information prior to an appointment, the staff of Wind City Eye Care makes every attempt to verify patient's benefits. In addition, the staff will gladly file insurance claims on behalf of the patient. The insurance carrier will review the claim and accept or deny coverage as they deem appropriate. Should the insurance company deny coverage, it is the patient's responsibility to pay any and all of the balance to Wind City Eye Care. To be better prepared, patients should attempt to know their coverage including deductibles, co-pays and noncovered services.

The staff of Wind City Eye Care can give you a general idea of what may or may not be covered by your insurance plan before seeing the doctor. However, we cannot always know for certain what services will be provided by the doctor before the examination.

Whether a visit will be filed with a vision carrier or medical carrier is dependent on several factors including but not limited to patient's reason for visit, type of exam performed, and diagnoses. Any diagnosis other than a routine diagnosis will result in a medical claim submittal. At times, patients may be able to use both medical and vision benefits to maximize patients' benefits.

By signing below, I acknowledge that I have read and understand the above.

• I AUTHORIZE THE USE OF THIS FORM ON ALL MY INSURANCE SUBMISSIONS.
• I AUTHORIZE RELEASE OF INFORMATION TO ALL MY INSURANCE COMPANIES.
• I UNDERSTAND THAT I AM RESPONSIBLE FOR MY BILL
• I AUTHORIZE MY DOCTOR TO ACT AS MY AGENT IN HELPING OBTAIN PAYMENT FROM MY INSURANCE COMPANIES
• I AUTHORIZE PAYMENT DIRECT TO MY DOCTOR.
• I AUTHORIZE A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL.
• I AUTHORIZE EMAILS & TEXT MESSAGES BE SENT TO ME FOR APPT REMINDERS, ORDER NOTIFICATIONS AND PROMOTIONAL OFFERS & EVENTS

When provided the necessary payment information at the end of an appointment, the staff of Wind City Eye Care makes every attempt to verify each patient's form of payment.

Under state and federal law, it is legal to allow another party to utilize your credit card with your permission. As the cardholder, you are in agreement to be held liable for any purchases that person(s) makes.

I understand the information that is listed above and I am in full agreement that

By signing below, I acknowledge that I have read and understand the above.