New Patient Packet Patient Details

New Patient Packet Insurance Information

New Patient Packet COVID Questionnaire

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New Patient Packet Pre-evaluation Questions

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New Patient Packet Medical Information

  •  Eyes
  •  Gastrointestinal
  •  Nerves
  •  Ears/Nose/Throat
  •  Genitourinary
  •  Endocrine
  •  Cardiovascular
  •  Musculoskeletal
  •  Blood/Lymph
  •  Respiratory
  •  Psychiatric
  •  Allergy
  •  Constitutional
  •  Immunologic
  •  Integumentary (Skin)
  •  None
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New Patient Packet Personal Eye Information

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  •  Glaucoma
  •  Cataracts
  •  Dry Eye
  •  Blurred Vision
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New Patient Packet Family History

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New Patient Packet Appointment Policy

We are grateful you have chosen Busby Eye Care as your vision care provider.  In order to serve our patients in the most timely and effective manner, the following policy has been established.
 
Each and every appointment we book is important to us and we want to ensure that each patient receives the highest quality of care. To do this, we reserve our doctors’ time especially for each patient we schedule and no one else. We also provide weekday, evening, and weekend appointments for our patients to make scheduling as convenient as possible.
 
We understand there are times when you must miss an appointment due to emergencies or other obligations which come up.  However, when you do not call us to cancel an appointment, you prevent us from reallocating the time to someone who is in urgent need of treatment.
 
For the purposes of this policy, a No Show is missing a scheduled appointment. A Late Cancellation is cancelling an appointment less than 24 hours prior to the scheduled time. Our policy is as follows:
 

Late Cancelation Fee      $25

No Show Fee                  $50
 
Also, as a courtesy to your family, we offer back-to-back appointment times for multiple family members. However, this requires a larger block of reserved time and 24 hours’ notice is absolutely crucial in the event you are unable to keep the appointments. If 24 hours’ notice is not given, a $25 fee per appointment will be imposed and family members will no longer be allowed to schedule together.
 
We understand situations such as medical emergencies occasionally arise when an appointment cannot be kept and adequate notice is not possible. These situations will be considered on a case by case basis, but the above charges will apply to most No Shows and Late Cancellations. We do provide a courtesy call to remind you of your visit 24-48 hours prior to your appointment, but it is your responsibility to know when your appointment is scheduled.
 
Please note you will be personally responsible for Late Cancelation and/or No Show charges as they cannot be billed to your insurance company. Future appointments will not be made until the fees are paid. If a patient accumulates a total of 3 No Show appointments, future appointments will not be scheduled.
 
I acknowledge I have received and agree to the Busby Eye Care Appointment Policy.

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New Patient Packet Financial Policy

The doctors and staff are committed to providing you with thorough, professional eye care. If you have medical insurance that covers eye care or other vision insurance, we will be glad to complete any forms you may have and assist you in obtaining your maximum allowable benefits.

Payment for services is due at the time the services are rendered unless other payment arrangements have been made and approved by our staff. This includes services provided for a minor patient. The guarantor is responsible for these charges. We prefer payment in full when ordering glasses or contacts. We accept cash, checks, Visa, MasterCard, Discover, American Express and Care Credit.

We are panel providers and accept assignment on several vision plans and Medicare Part B and DMERC. This means that at the time of the exam, you will be responsible for any co-payments, deductibles or fees for non-covered services. We will bill and receive payment directly from your insurance company for covered services. You will be responsible for any remaining balance. Please ask a staff member if we are panel providers and accept assignment for your plan prior to your examination.

If you need a referral from your primary provider to see us, it is your responsibility to obtain that referral prior to your examination. A referral with an authorization number is not a promise to pay for that visit. If for some reason you were not eligible for services at the time of the examination, your HMO, PPO or IPA may deny payment and you will still be responsible. Please realize that 1) Your insurance coverage is a contract between you and your insurance company. 2) Our fees for covered services normally fall within acceptable ranges set by most insurance companies and are usually covered up to the maximum allowance set by each carrier. IF this is not the case, the patient is still liable for the remaining balance. 3) Not all services are a covered benefit in all contracts and routine eye care and other selected procedures may be specifically excluded, making the patient responsible for all charges. We will try to furnish you with as much information as we can before you select a treatment option so that you can make the most informed decision possible.

We must emphasize that as eye care professionals, our relationship is with you and not your insurance company. You are ultimately responsible for all fees for both services and materials delivered to you by this office.

If you have any questions about the above information or your insurance coverage, please do not hesitate to ask. We are here to help you. Thank you.

I have read, understand and agree to the Financial Policy Statement above and have received a copy of the Busby Eye Care Privacy Policy. 

 

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New Patient Packet Authorization to Release Medical Information

To comply with HIPAA Regulations, we must receive your written approval to discuss your medical and/or billing information with anyone other than yourself.  This includes family members.  By signing this authorization, you give your permission for us to discuss your care, answer questions, leave detailed messages and contact in the event of an emergency, the person(s) listed below.  If you would like us to share your medical and/or billing information with anyone other than yourself, you must include them below.

For children under the age of 18, parents or legal gardians are automatically included and do not need to be added below. 

New Patient Packet Notice of Privacy Practices

HIPAA protects you and your personal health information while also allowing us to run our office efficiently. The Notice of Privacy Practices can be located on our website under patient forms and a paper copy may be given to you at any time by your request. 

I acknowledge that I have been offered and/or have received a copy of Busby Eye Care’s Notice of Privacy Practices.

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New Patient Packet Contact Lens Exam Agreement

If you are a current contact lens wearer, or are interested in wearing contact lenses, you will need a contact lens evaluation.
The contact lens evaluation fee is not included in the fee for your eye exam. The fee for your contact lens evaluation includes the initial visit and up to three subsequent visits directly related to contact lens wear within a 90 day period. The New Wearer fee includes an additional $25 to cover the cost of Insertion and Removal Training, subsequent fitting visits and trial lenses. ***Please note that before New Wearers can take home trials or have a prescription released to them, they must successfully complete the in-office training.
The fees for the contact lens exam are as follows:
New Wearer: (regular fee + $25, see above)


Conventional, Spherical Contact Lenses
Previous Wearer: $60
New Wearer: $85

Bifocal/Multifocal Contact Lenses
Previous Wearer: $100
New Wearer: $125
Monovision Contact Lenses
Previous Wearer: $80
New Wearer: $105
Toric Contact Lenses
Previous Wearer: $80
New Wearer: $105
Gas Permeable Contact Lenses
Previous Wearer: $80
New Wearer: $105
Duette Contact Lenses (Single Vision)
Previous Wearer: $110
New Wearer: $135
Duette Contact Lenses (Multifocal)
Previous Wearer: $155
New Wearer: $180
Corneal Refractive Therapy (CRT)
Previous Wearer: $200
New Wearer: $1,600
Scleral Contact Lenses
Previous Wearer: $1,100
New Wearer: $1,100


These fees are based on the amount of time needed for the fitting, whether or not you have worn that type of contact lens before, and the cost of any necessary trial lenses.
You are responsible for scheduling and attending your follow up visit in order to finalize your prescription. Without a finalized prescription, you will not be able to order contacts.
By signing below you are acknowledging that you have read and understood our contact lens policy and agree that you will pay in full at time of service.
_______________________________________________________________

IF YOU DO NOT WEAR CONTACT LENSES, PLEASE JUST CHECK NO AND SIGN. 

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