Acknowledgement of Patient Responsibility and EHR Disclosure

Patient Responsibility

I hereby acknowledge that I understand my benefits for services and materials, and that I am responsible for any balance on my account after my insurance has made payment.

Medical vs. Routine Examinations

I hereby acknowledge that if I am being seen for a medically-necessary reason (diabetes, macular degeneration, etc.) that my eye examination will be billed to my medical insurance. I understand that I am able to use my vision plan for any eyeglasses or contact lenses that I purchase from this office.

Deductibles and Co-Payments

I understand that I will be responsible for any deductibles that I have not yet met on my medical insurance. In addition, I understand that all co-payments are due at the time of service, and patients cannot be billed for co-payments.

Collections

I hereby acknowledge that any remaining balance is to be paid upon receipt of the first statement. In addition, I understand that if I do not make attempts to contact Miller Optometry, Inc. to setup payment arrangements on a delinquent balance that my account may be discussed and turned over to a collection agency.

Electronic Health Records Disclosure

Miller Optometry, Inc. is proud to be utilizing Electronic Health Records in our office. This change allows for a higher quality of care to be provided to our patients. However, due to federal insurance regulations, every medical professional using Electronic Health Records is required to record their patient’s height and weight (self-provided) and blood pressure (may be taken in-office).

Agree with everything you see?

By signing in the box below, you hereby acknowledge that I am aware of the patient / financial responsibilities for Miller Optometry, Inc. You understand that you are able to request a copy of this policy, or discuss any questions you may have regarding the privacy notice with your provider.