Patient Forms (Available as downloadable PDF files. Please print and bring them with you):
- New Patient Appointment Confirmation and Financial Policy Notification
- Medical History Questionnaire
- Assignment of Benefits/Financial Agreement
- Printable Medical Card
- Refraction Notice
- Visual Inventory
- HIPAA Notice of Privacy Practices
- Receipt of Notice of Privacy Practices
- Authorization to Disclose and Obtain Information
- Optional Payment Plan
Thank you for selecting Proffitt Eye Center for the care of your eyes. The entire staff welcomes you to our medical practice. We will make every effort to satisfy your needs.
Upon scheduling your appointment you will be given a Health History Form for completion. This form may be returned to us at the time of your appointment. You may expect your first visit to last 45 to 60 minutes. It is likely that dilation will be necessary therefore it is advisable to have a designated driver.
The best medical care can be provided only on the basis of mutual understanding. We encourage you to discuss any concerns you may have regarding your exam with our medical staff. We also ask that you discuss any questions you may have regarding our policies with our billing staff. In order to meet your financial obligations to our office and keep the necessary insurance paperwork as simple as possible, we ask that you observe the following policies. Payment is expected at the time of service for all procedures unless prior arrangements have been made.
Our office participates with the Medicare program (accepts assignment). We will file all claims to Medicare with a valid signature on file from the patient. Medicare does not cover routine eye exams and refractions therefore payment for these services is requested at the time of service.
Health Care Plans
We participate in a variety of insurance plans and will directly bill your insurance under these plans. In these circumstances, you are responsible for applicable co-payments (which are usually indicated on the insurance identification cards). If you have not met your deductible you may be asked to pay at the time of service. We cannot accept responsibility for negotiating claims with insurance companies. You are responsible for payment of your medical care within a reasonable time, regardless of the status of a claim. Services not covered by your insurance are your responsibility.
Please check your insurance handbook or check with your insurance company before scheduling an appointment to be sure you will be seeing a participating provider. Please also verify that the doctor you are scheduled to see remains in your network at the time of your visit. Some plans require you to obtain authorization from your primary care provider (internist, family practitioner, pediatrician, etc.) for services provided by specialists. It is your responsibility to obtain this authorization form from your primary care provider. If applicable, you must obtain this authorization before you visit our office. Failure to obtain a valid referral form may result in the patient being financially responsible for any charges incurred.
Claim Form Preparation (where we do not bill your insurance)
If you have insurance coverage through a carrier with which we don’t have a PPO contract, we provide an itemized statement (which is sometimes called a physician portion of the claim form). Most insurance companies will accept this statement along with their insurance claim form once you’ve completed the patient information portion. Our insurance staff will be happy to assist you with instructions for completing your claim form.
The refraction portion of the eye exam is performed to determine if glasses, or a change in your current spectacle correction, will provide the best possible vision of the eye. A written prescription is given if this would be helpful in improving the individual’s visual acuity level. Please be aware and informed that you may be refracted as part of the eye examination, and that most insurance plans, including Medicare, do not cover this portion of the examination. Therefore, payment is due at the time of service. If you have a separate Vision Plan that covers routine eye examinations, please let us know before your visit since it may assist you with your eye care needs that are not covered by your medical plan.
Coding Guidelines for Annual Examinations
The Center for Medicare and Medicaid Services (CMS) periodically makes changes to the coding guidelines that offices are required to follow. Please note that routine exams will be coded as such. We are not allowed to select a code based on your insurance company’s reimbursement policies. Please let us know if you have any questions.
We will file your claim with Workers Comp if you provide us with information regarding your employer and have taken the necessary steps with your employer.
If billing is necessary, a statement will be mailed to you that is due days upon receipt. Charges and payments for services received during the last few days before your billing date may appear on the following month’s statement.
For your convenience, we accept VISA, MasterCard, and bank debit cards. We also offer a Care Credit program which offers no interest financing for the first 12 months for charges meeting a minimum balance requirement. Our staff is willing to discuss this option with you.
Please bring all health insurance information with you along with your Driver’s License or photo ID, for security purposes. We will need a copy of any insurance cards for our records. If you have any questions regarding Medicare and insurance policies and procedures, do not hesitate to ask. We will do our best to assist you.
During your visit, please feel free to ask any questions about your eyesight. We will be glad to answer those questions and provide you with additional written information that we have available.