Sumner and Birkmann Financial Form

Patient Name

Insured Name

Financial Responsibility: I authorize the release of medical and financial information for the purpose of collection of my account.

 If my DOCTOR IS A PARTICIPATING PROVIDER with my insurance plan I authorize my insurance benefits to be paid directly to the doctor and acknowledge that I am financially responsible for any unpaid balance. I agree to pay this balance in full.  If my DOCTOR IS NOT A PARTICIPATING PROVIDER with my insurance plan, I understand that I bear sole financial responsibility for the payment of my account. As a courtesy to our patients claim forms will be submitted to nonparticipating insurance companies. Because benefits from nonparticipating insurance companies are refunded directly to the patient, we require that the balance be paid in full before we submit the claim forms.

Drs. Sumner and Birkmann accept the following medical plans:

Aetna, Anthem Blue Choice, Beech Street, Cigna, Coventry, Evercare, GHP, Healthlink, Healthnet, Humana, Medicare, Medicare Complete, Mercy Health Plans, MultiPlan, PHCS, Premier, Principal, Secure Horizons, Tricare/Champus, United Health Care

These vision plans are accepted:

Blue View Vision, EyeMed, Mercy Health Vision Plan, Vsp

 INSURED AGREEMENT: I am aware that my insurance carrier may require me to use participating providers and to follow plan requirements, including primary care referral and precertification and that failure to comply could result in my sole responsibility to pay any charges for services rendered.  SELF PAY AGREEMENT: I do not have any insurance coverage or if this service is not covered by my insurance earner, I agree to be responsible for the full balance.

Payment is expected in full at the time services are rendered. Payment of one half is expected before eyeglasses or contacts will be ordered. Eyeglasses and contact lenses must be paid in full at the time of dispensing.

I hereby instruct and direct

Insurance company to pay by check made out and mailed to: Sumner and Birkmann Optometrists, P.C. 320 Washington Ave. Washington MO 63090

Desired method of payment

Cash
Check
Credit Card

Signature or Patient or Guardian

Date Signed

SS# of Patient

Employer

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insurance Company

Policy #

Secondary Insurance

Policy #

Medicare Payment & Medical Records Release Authorization

I request that payment of authorized Medicare benefits be made on my behalf to the office of Drs. Sumner and Birkmann for any services furnished to me by this provider. I authorize the release of medical and financial information to the Health Care Financing Administration and its agents to determine benefits payable for services from this provider. I request payment of authorized medigap (secondary insurance) benefits be made to this provider and also authorize the release of medical information to the medigap insurer to determine benefits payable for services from this provider.

Name

First Last

Medicare #

Name of Medigap Insurer (secondary insurance)

Medigap policy# (secondary insurance policy #)

Patient's Signature

Date Signed