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Home » Contact Us » Hipaa Form

Hipaa Form

  • AUTHORIZATION & ACKNOWLEDGEMENT

  • Parents, if your child is under the age of 18, please sign for the following
  • We are proud to offer the latest technology for your eye exam, the OPTOS DAYTONA.  The Optos Daytona is a retina imaging system that offers an ultra-wide digital image of the inside of your eye, called an OPTOMAP.  This is done without the use of dilating eye drops.  This image allows the doctor to view approximately 80% of the retina inside your eye, and makes it possible to diagnose eye disease early and more thoroughly.  This scan becomes a permanent part of your medical file which allows accurate comparisons at each yearly eye exam. Our doctors believe the OPTOMAP to be an essential part of your eye exam and prescribe it for all patients once a year.
  • Release of Information

  • Patient Financial Agreement

  • About Your Insurance

  • There are two types of health insurance that will help pay for your eye care services and optical products. You may have both types and Atkinson Eye Care accepts insurance plans in both categories: 1) Vision plans (such as VSP and EyeMed) and 2) Medical insurance (such as Blue Cross/Blue Shield, Medicare and others).
    • Vision plans only cover routine vision wellness exams, along with eyeglasses and contact lenses. Vision plans do not cover medical eye care (the diagnosis, management or treatment of eye health problems).
    • Medical insurance must be used for medical eye care.
    • If you have both types of insurance plans it may be necessary for us to bill some services to one plan and some services to the other. We will follow a procedure called coordination of benefits to do this properly and to minimize your out-of-pocket expense.
    • If some fees are not paid by your insurance, we will bill you for them, such as deductibles, co-pays or non-covered services as allowed by the insurance contract.
    Please provide your insurance cards to our staff member so we can make a copy. We need to have your medical insurance card or Medicare card on file in case we should need it in the future for billing your insurance.
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