4081 Superior Vision Registration Form

  • Welcome to Superior Vision

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Questions

  • EYE AND GENERAL HEALTH HISTORY

  • Family History (Blood Relatives only: Mark Relation, i.e. Mother, Father, Grandparent' Aunt)

  • Financial Policy

    A clear understanding of our Financial Policy is an important part of our professional relationship. We are pleased to discuss the financial aspects of your care. Feel free to ask questions regarding your fees, financial responsibilities, insurance coverage, or the Financial Policy. All patients must complete the "New Patient" forms before seeing the Doctor. The following forms of payment are accepted: Cash, Personal Checks, Debit Cards, Care Credit, Health Savings Cards, VISA, MASTERCARD, AMERICAN EXPRESS, and DISCOVER.
  • INSURANCE

    Each insurance plan is different and it is YOUR responsibility to check with your insurance company regarding coverage prior to your appointment. Please remember too that we file the insurance as a courtesy for you, and we will attempt to collect on all claims. Failure to pay by the insurance company for any reason will result in the bill becoming your responsibility. Insurance is a contract between you and your insurance company. Our office will NOT become involved in disputes between you and your insurance regarding deductibles, co-payments, covered charges, or secondary insurance other than to provide information regarding the services provided by our practice. We will file with most insurances: however, we are not contracted with SPECTERA at this time. When a doctor contracts with an insurance company, the doctor is considered "in network". The insurance company has specific payment schedules for both "in network" and "out of network" providers. For example, a plan that pays 80% for an "in network" provider may only cover 60% for an "out of network" provider. You will be responsible for the portion that is not covered by your insurance.
  • MEDICAID

    We do cunently accept Medicaid. providing that you are eligible for that date of service. If you are NOT eligible, the charges for that day will be your responsibility and you will be required to pay the bill. Sometimes, the Medicaid eligibility slip shows that the patient has a primary insurance. Medicaid is always regarded as secondary insurance and will NOT pay until the insurances outlines on the slip have been billed. We understand that sometimes theses primary insurances are outdated, but we have no choice but to file with them. You are responsible for providing us with this primary insurance information. If you care to dispute the insurances, you will need to contact your caseworker.
  • RELEASE OF OPTICAL INFORMATION

  • I hereby give permission to release my optical information (for purpose of collection of my optical bill) by means of electronic submission, mail, far, or phone I hereby give permission to contact me via phone, answering machine, and/postcard to remind me of my optical appointments or need for optical re-care
  • PAST DUE ACCOUNTS

    If it becomes necessary for our office to use a collection agency or legal representation to collect a seriously past due account, you will be liable for any fees incurred during the collection process. If you have any questions or concerns, please let us know.
  • I have read and understand the financial policy and agree to the terms as stated above.
  • Retinal images are an essential part of your annual comprehensive eye exam.

    Optomap: When reviewed, the scan becomes a permanent part of your medical record, enabling the doctor to make an important comparison should potential vision-threatening conditions show themselves at a future examination. Retinal problems such as macular degeneration, glaucoma, retinal holes, retinal detachments, diabetic retinopathy, and many systemic diseases can now be seen without dilation* for most patients. The doctors at Superior Vision highly recommend Optomap imaging for all patients on an annual basis. Optomap imaging allows the doctor to compare ocular health changes and early detection of many ocular diseases
  • I have read and understand this document:

  • Date Format: MM slash DD slash YYYY