RETINA CONSULTANTS OF HOUSTON. Date of Birth: Age: Sex: M F Martial Status: S M W D. Name of Spouse: Emergency Contact Name: Number:

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1 RETINA CONSULTANTS OF HOUSTON 6560 FANNIN, SUITE 750, HOUSTON TX PATIENT INFORMATION Patient's Legal Name: Date of Today's Visit: Social Security # Date of Birth: Age: Sex: M F Martial Status: S M W D Address: (Street) (City, State, Zip) Address: Phone #: Cell #: Work #: Name of Spouse: Emergency Contact Name: Number: Name of Referring Physician: Phone # of Referring Physician: Date of Last Exam with Referring Physician: Name of Primary Care Physician: Occupation: Phone # of Primary Care Physician: Is This a Work Related Injury? Employer: Employer's Address: PRIMARY INSURANCE INFORMATION Insurance Co.: ID #: Group #: Insured's Name: Relationship to Patient Self Spouse Dependent Insured's Employer: Phone #: Employer's Address: Insured's Social Security #: Date of Birth: Sex M F SECONDARY INSURANCE INFORMATION Insurance Co.: ID #: Group #: Insured's Name: Relationship to Patient Self Spouse Dependent Insured's Employer: Phone #: Employer's Address: Insured's Social Security #: Date of Birth: Sex M F Page 1 of 3

2 RETINA CONSULTANTS OF HOUSTON 6560 FANNIN, SUITE 750, HOUSTON TX AUTHORIZATION AND ACKNOWLEDGEMENT I hereby assign, transfer, and set over to Retina Consultants of Houston all my rights, title, and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of my medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand if I revoke this authorization that I am financially responsible for all charges whether or not they are covered by my insurance at the time of service. Patient/Guardian Signature Date Patient/Guardian Name (Printed) Witness Signature Witness (Printed) INSURANCE SERVICES Retina Consultants of Houston is contracted with many insurances. As a courtesy to our patients, we file claims to insurances with which we are contracted. If you are covered by an insurance with which we are not contracted, you will be considered self-pay in our office and payment will be due at the time of service. We do not file claims to out of network insurance plans, automobile insurances, and workers compensation Retina Consultants of Houston makes every attempt to verify insurance coverage and benefits prior to your visit. If we are unable to verify coverage with your insurance carrier, you will be asked to pay for your visit in full, or reschedule your appointment until we are able to establish verification with your insurance company. Verification of coverage will be used to estimate your financial responsibility which is due at the time of service; however, this verification is not a guarantee by your health plan of coverage or payment. While we may estimate your financial responsibility, your insurance company or companies make the final determination regarding your eligibility and benefits once claims are received. Your estimated financial responsibility will include known deductibles, copays and coinsurances due for the visit. In some cases, your insurance company may not provide coverage for office procedures or services that our office provides. Either your plan does not cover the procedure or service, or the procedure or service may be considered not medical necessary, experimental, or cosmetic by your insurance health plan. It is your responsibility to know the benefits of your current healthcare coverage. It is the patient s responsibility to obtain referrals for office visits and provide a copy to our office. Page 2 of 3

3 RETINA CONSULTANTS OF HOUSTON 6560 FANNIN, SUITE 750, HOUSTON TX WEEKEND/ON CALL VISITS In the event you see our physicians after hours or on the weekend, we may be unable to verify insurance coverage prior to your visit. If you are seen by one of our physicians and we are not contracted with your insurance health plan, you will be responsible for the visit in its entirety. It is your responsibility to know your current healthcare coverage, which includes if our physicians are contracted with your current health plan carrier. Patient/Guardian Signature Date Patient/Guardian Name (Printed) FINANCIAL POLICY Payment is due in full at the time services are rendered. We accept cash, check, and credit cards (Mastercard, Visa, Discover, American Express). Post-dated checks will not be accepted by our office. Please be prepared to provide our office with a copy of your insurance card (s) and picture identification every time you visit our practice. Each time you visit our office you may be required to update your personal information such as home address, contact phone numbers, and emergency contact phone numbers. If there are any changes in the patient s insurance, it is the patient s responsibility to notify our office prior to your visit. If the information is not provided prior to the visit, the patient could be responsible for charges incurred for any dates of service prior to the new information being given. Physician surgical fees owed are due prior to any surgery performed by one of the doctors in the various hospitals we perform surgery in. This would include any deductible, copay or coinsurance. Fees quoted by our office for surgery are for the surgeon only. Financial responsibility for a minor is the responsibility of the accompanying adult unless arrangements have been made prior to the visit. Any PAST DUE BALANCE is required to be paid either by the statement received from our billing office, or at the time of your next visit. In the event your account is past due, we will take the necessary steps to collect the debt, and possible referral to a collection agency which could affect your credit record. SELF PAY/CASH PAY POLICY: For patients who are not using insurance for their office visit, a $250 deposit will be due at CHECK-IN. (Cash or Credit Cards are accepted). This deposit will be applied to the actual charges at check-out. If the visit charges exceed $250, the remaining balance is due at check-out. In the event the charges are less than $250, the difference will be refunded at check-out. Patient/Guardian Signature Date Patient/Guardian Name (Printed) Page 3 of 3

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