New Patient Form


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Employment:            Yes        No        Retired
Gender:    Male     Female    
Marital Status:            Single        Married        Divorced        Widowed




  • I authorize and consent to the professional services rendered to the above patient. Authorization is given to release information as may be necessary for the completion of medical insurance claims, the benefits of which may be assigned to the physician at his option.

  • I agree to pay interest on any uncollected amount of debt to Bay Eyes Cataract & Laser Center, P. C. & Bay Eyes Surgery Center d/b/a VisionaryUSA.com Surgery Institute. I agree to pay the cost of collection for past due debt. I acknowledge responsibility for the payment of services rendered, and agree to pay for them at the time of service. Co-pays, fitting fees and refractions not covered by insurance will be paid at the time of service.

  • By signing below, you hereby consent for this practice to use or disclose information about yourself (or another person for whom you have the authority to sign) that is protected under federal law, for the sole purpose of treatment, payment and healthcare operations. You may refuse to share your information.

  • You should read the Notice of Privacy Policies for PHI located at the front desk or the lobby copy provided at the doctor's office before you sign the consent form. If you would like a personal copy, please ask the front desk receptionist. The terms of the Notice may change from time to time, and you may always get a revised copy of it by asking the Privacy Officer of this practice.

  • You have the right to request that this practice restrict how PHI is used or disclosed to carry out treatment, payment or health care operations. This practice is not required to agree to requested restrictions; however, if the practice does agree to your requested restrictions, the restriction is binding on it.

  • Information about you is protected under federal law, and you have the right to revoke this consent, unless we have taken action in reliance on your authorization (as determined by our Privacy Officer). By signing below, you recognize that the protected health information used or disclosed pursuant to the consent may be subject to re-disclosure by the recipient and may no longer be protected under federal law.

  • You may communicate with the following individual(s) regarding my condition or course of treatment(s):

  • You may communicate confidential information to me at the address and phone numbers listed above or at the following:



Thank you for choosing our office to provide your eye care. We appreciate your trust and look forward to working with you. In order to prevent any misunderstanding, and to better serve you, we ask that all patients read and sign our Financial Policy. If you have any questions, please ask.

  • VERIFYING INSURANCE: As a courtesy to our patients, we will verify insurance for eligibility benefits prior to the first appointment, as well as any time we are notified of a change in coverage. The insurance companies do not guarantee payment based on the information that they provide us. You are ultimately responsible for knowing if there are any waiting periods for work to be performed. Any amount on your treatment plan that is not covered by your insurance is your financial responsibility.

  • INSURANCE INFORMATION: New insurance, as well as changes in insurance, must be provided to our office prior to your appointment. Accepting assignment of benefit from your insurance company is the equivalent of extending your credit; therefore we must have your Social Security Number on file. If you choose not to provide us with your Social Security Number, you will be responsible for payment in full at the time services are rendered.

  • CHANGES IN PERSONAL INFORMATION: Changes in your address or telephone numbers should be provided to us immediately. If this office is unable to contact you by telephone or mail and your balance is overdue, your account will be sent to a collection agency.

  • REQUESTS FOR ADDITIONAL INFORMATION: These must be responded to immediately. Such requests include proof of a college student's full-time status and proof of continued enrollment in any insurance plan. Failure to provide this information to the insurance company in a timely manner may result in the entire balance being your responsibil- ity.

  • PAYMENT: Payment is due at the time of service. Additionally, if you have a balance following a previous visit, you will be expected to pay that amount as well. If payment is made directly to you for services billed by Bay Eyes, you agree to promptly remit payment to Bay Eyes.

  • PAYMENT PLANS: In addition to cash, checks, Visa, MasterCard, and Discover, we offer several payment plans— please see our staff for details.

  • REFUNDS: Overpayments will be refunded to the appropriate party, normally the insurance company or the guarantor. Patients' refunds will not be processed until all active or past due accounts and insurance claims have been paid in full. Any balances of $25 or less will remain on account for ninety (90) days, and if not used will be adjusted off the account.

  • RETURNED CHECKS: There will be a $30 fee for all returned checks. The amount of the check plus the fee must be paid within 10 days of notification by money order, cash, or credit card. Once a check has been returned, this office will no longer accept personal checks for payment.



REFRACTION This test determines your need for lenses to correct the refractive error to your vision. This is your eyeglass prescription.

  • We expect your health insurance may not pay for this testing. If your health insurance does not pay for the refraction, you may have to pay. If you have vision insurance, this testing should be covered under your vision plan.
  • Refraction entails 60 days of follow-up care.
  • Reason my health insurance may not pay- Your health insurance may not deem a refraction to be medically necessary. Most insurance plans cover the visit for the healthcare of the eye but not for vision correction (eyeglass prescription).
  • Estimated cost- $30.00

OPTIONS Check only one box. We cannot choose a box for you.

  • OPTION 1. I want the testing listed above. I would like my insurance company to be billed and to receive an official decision of payment sent to me as an explanation of benefits. I understand that if my insurance does not pay for the testing, I am responsible for payment. I may be asked to pay for this service now, but I can appeal to my insurance company for repayment by following the directions on my insurance forms. If my insurance company does then pay, you will refund any payment I made to you, less any co-pays or deductibles.

  • OPTION 2. I want the testing listed above, but do not bill my insurance company. I may be asked to pay now as I am responsible for payment. I know I cannot appeal this decision if my insurance is not billed.

  • OPTION 3. I do not want the testing listed above. I understand with this choice I am not responsible for payment, and know that I cannot appeal to my insurance for payment of service.

CONTACT LENS FITTING ALL contact lens wearers require a contact lens fitting & evaluation every year. In so doing, the doctor checks your eyes to make sure your cornea, lids, and lashes are healthy, and that your vision is stable while wearing contact lenses.

  • If you are a first time contact lens wearer, the doctor will determine if you are a candidate for contact lenses. If you are an existing contact lens wearer, the doctor must evaluate your current lenses to assure satisfactory fit and vision.
  • Contact Lens Fitting entails 90 days of follow-up care for contact lens use and proper fit.
  • We expect your health insurance may not pay for this testing. If your health insurance does not pay for the fitting, you may have to pay. If you have vision insurance, this fee may be covered in full or at a reduced rate according to your policy.
  • Reason my health insurance may not pay- Your health insurance may not deem this testing to be medically necessary. Most insurance plans cover the visit for the healthcare of the eye but not for vision correction (contact lens prescription)
  • Estimated cost- $75.00 for your initial evaluation or $55.00 for our established wearers, as determined by the doctor. · Contact Lens Fitting Fee is due even if we are unable to determine a contact lens tolerance.

    OPTIONS Check only one box. We cannot choose a box for you.

  • OPTION 1. I want the testing listed above. I would like my insurance company to be billed and to receive an official decision of payment sent to me as an explanation of benefits. I understand that if my insurance does not pay for the testing, I am responsible for payment. I may be asked to pay for this service now, but I can appeal to my insurance company for repayment by following the directions on my insurance forms. If my insurance company does then pay, you will refund any payment I made to you, less any co-pays or deductibles.

  • OPTION 2. I want the testing listed above, but do not bill my insurance company. I may be asked to pay now as I am personally responsible for payment. I know I cannot appeal this decision if my insurance is not billed.

  • OPTION 3. I do not want the testing listed above. I understand with this choice I am not responsible for payment, and know that I cannot appeal to my insurance for payment of service.

By signing below I indicate that I have read and understood this notice, and that I may receive a copy upon request.


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