Step 1 of 11
Most people have both vision and medical insurance. They are very different in the terms of the services they cover, and it is important to understand those differences. Vision coverage is mainly designed to determine a prescritption for glasses, help pay for glasses or contacts, and to screen for medical conditions. It is not designed to be used for medical condtions, diagnostic or screening tests or treatment plans. Some medical plans have a vision benefit.
When a medical diagnosis or condition is present (such as diabetes) or an eye disease(such as infections, dry eye, allergies, cataracts etc), it is necessary to file the claim for your visit to your medical plan and the co-pays, co-insurance, non-covered services and deductibles apply. Vision insurance does not cover medical eye problems. Our office does not make the rules; they are defined by insurance carriers and we are required to follow them.
In most cases, it is difficult to know prior to examination which type of insurance will apply or with whom our office will be able to file a claim for you. We make every effort to determine as much information for you in advance. We require you present both your vision(if you have one) and medical insurance cards at check in.
I understand the paragraphs above and authorize Vision Source to file a claim on my behalf, and I understand that I am responsible for any co-pays, co-insurance or deductible not yet met.
Insurance Service Waiver: I authorize the release of all medical information necessary to process insurance claims pertaining to my medical care or information necessary to process vision plan claims. As a member of my individual insurance plan, I understand that I am liable for all costs associated with my office visit if:
Signature on file: I certify that the information given by me in applying for payment under title XVIII of the Social Security Act is correct.
(x) I authorize use of this form on all my insurance submissions
(x) I authorize release of information to all my Insurance Companies.
(x) I authorize my doctor to act as my agent in helping me obtain payment from my Insurance Company.
(x) I authorize payment direct to my doctor or group practice
(x) I permit a copy of this authorization to be used in place of the original
(x) I permit text and email to be sent to the number on file
Acknowledgement of Review of Notice of Privacy Practices:
I acknowledge that I read a copy or have been offered a copy of the Vision Source Notice of Privacy Practices, which explains how my medical information will be used or disclosed.
At the time of your exam, the following protocols will be implemented:
Superwide field retinal imaging (Optomap) will be performed on all patients with a fee of $39.00. This important test allows us to utilize the most advance technology available to evaluate your retina. It is better and easier to preform the eye exam for most patients and reduces the need for dilation of the eye in most patients.
If you need to reschedule your appointment, we ask that you give us 48 hours notice. All appointments must be confirmed 48 hours in advance by either phone or electronic messaging or your appointment may not be held. If you miss your appointment without calling in advance, there will be a $45.00 reschedule fee.
COVID and General Health
If you are sick, have flue like symptoms, or test postive for COVID in the past 7 days, please reschedule your appointment.
Masks are optional per Massachusetts Department of Public Health.
Please sanitze your hands upon entering the office.
Our office will be disinfect each pre-test and exam room between every patient.
Patient Phone Number:
I, ____________________________, hereby authorize Vision Source of Worcester/Spencer to (obtain / release) my medical records pertaining to services provided under the following conditions: 1. Specific description of the information to be used or disclosed: ____________________________________________________________________________________________________________________________________2. Persons/organizations who may receive my information: ___________________________________________________________________________________________________________________________________ 3. Description of each purpose of the use or disclosure of health information: ____________________________________________________________________________________________________________________________________
This authorization will remain effective from the date of signature until it expires on: _____________________.
It is entirely your decision whether or not to choose to sign this authorization form. We cannot refuse to treat you if you choose not to sign this authorization. You may also review your health information that we have on file before deciding whether or not to sign this form. Our Notice of Privacy Practices explains how you may request access to your identifiable health information and how we may respond. You will need to send a written request to the office contact person to initiate the process. If you sign this authorization you may revoke it at a later date, unless we have already acted in reliance upon the authorization. If you would like to revoke your authorization, please send us a written or electronic statement notifying us that the authorization has been revoked. When your health information has been disclosed as stated in this authorization, the recipient has no duty to protect its confidentiality. The recipient may re-disclose the information as they wish. I have read and understood this form. I am signing voluntarily. I authorize the disclosure of my health information as described above.
Signature: ________________________________________ Date: __________________________
If signing as a personal representative of the patient, state the relationship to the patient and the source of authority to sign this form.
Relationship to patient: _____________________________ Print Name: ______________________