Medical Information Release Form Name: First Last Date of Birth: MM slash DD slash YYYY Release of Information I authorize the release of information including the diagnosis, records, examination rendered to me and claims information. This information may be released to: Spouse Children Other Spouse name Child name please specify Information is not to be released to anyone. This Release of Information will remain in effect until terminated by me in writing. Messages Please call my home my work my cell phone number:If unable to reach me: you may leave a detailed message please leave a message asking me to return your call else else elseThe best time to reach me is (day) between (time) SignedDate MM slash DD slash YYYY Communication Release Form Our office is now utilizing secure text messaging and email to communicate clinical information to our patients due to poor telephone communication and the need for a more accurate and responsive mode of communication. We are now shifting our practice to an email and texting format. Texting can offer patients numerous advantages for clinical care due to its fast and efficient means of sending information. Our doctors prescribes medications electronically which require an updated email address. Text message examples: Appointment reminders Status of your glasses/lenses order Status of your contact lens order Emergencies The Eye Center at Jackson always protects your privacy. We will not share your personal information with anyone for any reason. Name First Last Email Cell Phone Number:SignedDate MM slash DD slash YYYY Patient Financial Responsibility Disclosure Statement Medical Insurance We have contracts with many insurance companies. We will bill them as a service for you. As the Patient or Responsible Party, you are responsible for any balance if your insurance company refuses to pay for any reason. The person signing on behalf of the Patient as the Responsible Party must: Please check off the following: Inform The Eye Center at Jackson of the current address and/or phone number for the Patient and Responsible Party. Present all current insurance cards (Vision and Medical) prior to each visit. Pay any required co-pay at the time of visit. Pay any additional amount owing within 30 days of receiving a statement from our office. Pay any required insurance deductible. Please note refractions (The test to ensure your vision through your glasses is at its best) are not covered by most insurances. Therefore we will collect $45. Please note a refraction costs $90 and we are offering you a 50% discount if paid at the time of your visit. If your insurance reimburses us, we will gladly reimburse you. If you decline to pay this fee at the time of your visit and the insurance company denies your claim, you will be charged the original $90. This does not apply to patients with VSP/Eyemed. I also understand that certain procedures such as the Optomap /Retinal Scan, Corneal Scan and Contact Lens Fitting are patient “elective” procedures and I will pay at the time of service the cost as it is not covered by insurance. Non-Payment on Account Should Collection proceedings or other legal action become necessary to collect overdue amount, the patient’s Responsible Party should understand that The Eye Center at Jackson has the right to disclose to an outside Collection Agency all relevant personal and account information necessary to collect payment for services rendered. The Patient or patient’s Responsible Party understands that they are responsible for all costs of collection costs and attorney fees, in addition to their outstanding balance. By signing below, you agree to accept full financial responsibility as a Patient who is receiving medical and/or vision services or as the Responsible Party for minor patients. Your signature verifies that you have read the above disclosure statement, understand your responsibilities and agree to these terms.
