Patient Registration Online Form

Eye Care Provider

I agree to pay for the services rendered and the materials fabricated at my request. I request that payment of authorized Medicare / Medicaid / Medigap or other Health / Vision Care insurance benefits be made either to me or on my behalf to Hopewell - Lambertville Eye Associates and/or suppliers for any services furnished to me by that provider of service or supplier.  I authorize any holder of medical information or Medicare information about me to be released to the Health Care Financing Administration and its agents or other insurance(s), or Medigap Insurer (  ) , to include any information needed to determine these benefits or the benefits payable for related services.

There are several procedures that may or may not be  covered by the medical nor the vision plan: A procedure is only covered based on Insurance CPT – ICD guidelines.

Some of the procedures are as follows: Refraction (not covered by medicare); corneal topography -  aberoometry, Diabetic Clearpath, Wellness Imaging, Dry Eye Procedures (MIBO), and imaging if combined with dilation.

Responsibility for Payment of Services Rendered  

I agree to pay for the services rendered and the materials fabricated at my request and acknowledge that my insurance company can deny payment for services.   I agree that if my insurance carrier does not pay Hopewell - Lambertville Eye Associates within 90 calendar days after submission, for services rendered to me, I shall take full responsibility for these charges.  If an insurance payment is received after I have reconciled with Hopewell - Lambertville Eye Associates, I will be refunded the amount of payment stated on the “explanation of benefits” provided by my carrier.

Accept Responsibilities for Payment of Diagnostic Procedures Not Covered By Insurance

It is possible that some of the procedures performed during the eye examination may not be covered by my vision or medical insurance. It has been explained to me the importance and reason for these specific eye care procedures which may or may not be covered by my insurance. If these procedures are not a covered benefit, I will accept the responsibility for the payment of non- - covered charges.  If I should choose not to have a procedure completed, I will not hold Hopewell - Lambertville Eye Associates responsible for any financial nor medical ramifications due to my actions.  

Health Insurance Portability and Accountability Act  of 1996

(Privacy of Patient Records)

• Have other licensed medical providers who(m) might / will assist in your medical and / or eyecare
• Your insurance carrier in order to process claims and / or a federal or state agency mandates for public health concerns.
• Be able to send you reminders of care utilizing healthcare codes in order to assist in your acquisition of referrals when required.
• If a copy of records are requested by yourself or designated legal guardian, a separate "Record Release" form must be signed by the individual and / or guardian. Records can then be released to the authorized party.
• Your records are held safe within the confines of our office with limited access to doctors and staff.

I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the practice’s Privacy Contact at [84 East Broad Street, Hopewell, NJ 08525 or 16 South Franklin Street, Lambertville, NJ 08530]. I understand that a revocation is not effective to the extent that my physician has relied on the use or disclosure of the protected health information or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

My physician will not condition my treatment, payment, enrollment in a health plan or eligibility for benefits (if applicable) on whether I provide authorization for the requested use or disclosure except:  (1) if my treatment is related to research, or (2) health care services are provided to me solely for the purpose of creating protected health information for disclosure to a third party. The use or disclosure requested under this authorization will result in direct or indirect remuneration to my physician from a third party.

Medicare Beneficiary Agreement    

(Medicare only – used if Medicare will deny payment of services)

Medicare will only pay for services that it determines to be reasonable and necessary under section 1862(a)(1) of the Medicare law.  If  Medicare determines that a particular service, although it would otherwise be covered, is “not reasonable and necessary” under Medicare program standards, Medicare will deny payment for that service. Medicare is likely to deny payment for the following procedures as non - covered procedures: {Refraction (92015), Anterior Segment Photos (92285), Spectacles or Contact Lenses are non-covered items by Medicare other than post-operative cataract extraction,

I have been notified by my physician, at Hopewell - Lambertville Eye Associates, that he or she believes that, in my case, Medicare is likely to deny payment for the service(s) identified above, for the reason(s) stated. If Medicare denies payment, I agree to be personally and fully responsible for payment.

TO ALL MANAGED CARE – VISION PLAN and Medicare PATIENTS

These plans are vision only (annual –  wellness - preventative health care related). These are not medical plans. Medical concerns, in general, will require a return visit with a referral. Certain procedures may not be covered by your plan such as corneal topography, automated screening visual fields, and dilated retinal examination. A dilated retinal examination (the use of drops to fully examine the internal eye health) is considered the most important part of the examination. **Additionally, contact lens fitting and progress evaluations are not considered as part of the annual examine as defined by vision policies. Therefore, there will be an additional charge for lens evaluations as well as any lens refit (if required).

Eyeglass Benefits

Hopewell – Lambertville Eye Associates, by contract with the various vision plans, have a selection of frames or contact lenses specified by your carrier.  However, we feel that as a courtesy to our patients, we have extended this benefit above and beyond what we are contracted to offer.  All plans have a “retail” allowance in lieu of their specified frame selection. Please check with our staff if this is an option.

Contact Lens Benefits

Professional and Products Fees

All additional professional and product fees due, inclusive of co-payments, charges on eyeglasses or contact lenses are required  to be paid in full prior any order processing.

The patient understands the all above statements and will assume the listed payment responsibilities.