By signing below, I give Maine Optometry, P.A. my permission as the Patient/Legal Guardian/ POA to release my Personal Health Information (PHI) in accordance with established H.I.P.A.A laws for the following:
To release any information regarding my diagnosis and care to my primary care physician (PCP) and any other physicians involved in managing my conditions
To act on my behalf regarding any and all contact with my insurance carrier(s) and also to release any information regarding my diagnosis and care with the primary insurance carrier and any other supplemental insurance carriers
To bill my Insurance company for any services which I have received and understand that regardless of my Insurance status, I am ultimately responsible for any balance on my account. It is also my responsibility to obtain any necessary referrals in a timely manner (3-5 days) from my PCP. If Maine Optometry, P.A. does not receive my referral, I will be responsible for the full payment of services provided. I further understand that any payment due that is delinquent past 30 days is subject to a $15.00 per month billing charge.
By signing I am also aware that any balance due over 90 days may be reported to the Maine Credit Bureau Reporting Service. And that I've been informed that I will be notified by Maine Optometry, P.A. prior to reporting my delinquent account and that the delinquency will stay on my financial record for 7 years.
I also understand that any diagnosis found to be medical in nature during any examination/follow up that it will be sent to my medical insurance provider and that if during my routine preventative eye exam any medical diagnosis (i.e. Cataract, Dry Eye Syndrome, Allergies, Glaucoma etc.) are found, that my routine exam may be considered medical and will be sent to my medical insurance provider for coverage regardless or any vision specific coverage.