New Patient Forms-Adult Patient

From your first phone call to the time you check out, our entire staff strives to serve you well. We are committed to providing care of the highest quality and treating you as we would want to be treated.

Office Information

Children's Eye Center of South Texas, PA

1439 E. Sonterra
San Antonio, TX 78258

Phone: 210·340·6633 Fax: 210·340·6390

www.kidseyes.net

Your Children’s Eye Center Vision Team

Hours: Monday thru Thursday 8:00 AM to 5:00 PM, Fridays 8:00 AM to 12:00 PM. Closed on all major holidays. Telephones are not answered between 12:00-1:00 PM

Welcome to CEC!

Please know that our clinic is a very busy clinic at all times. A few tips to help with your visit is to make sure that you bring your insurance ID and identification such as your driver's license or custody papers if applicable. Please do not come earlier than 15 minutes to your appointment and try not to be late. If you are running late, please call. We may not be able to see your child. Always confirm or cancel your appointments. This allows patients who are waiting to get in. Please remember that this clinic does work in patients due to emergencies from all over South Texas and some times visits may take longer. We apologize in advance, however this is a necessary service provided to the community. If there are problems such as inclement weather or other information regarding the clinic, we have a Facebook page for up to date information.

Our intention is to provide excellent care and service to you and your child. If for some reason, we are unsuccessful, please ask to speak with Kevin, our Administrator (kevin@kidseyes.net) during your visit.

APPOINTMENTS

To make an appointment, please call (210) 340-6633. Our clinic currently uses an appointment reminder service. This service is to remind you of your appointment 7 days in advance. Please listen to or read the entire message and confirm your appointment or reschedule as necessary. We ask that you if you need to discuss your appointments, please do not leave a message, but call back during regular office hours. Follow up appointments, if needed, will be scheduled upon checkout after your visit. Annual reminders will be sent out via text message or email. Also, always bring your child’s glasses and your insurance card with you to each visit. If you move or change your number, please contact us with your new address and phone number.

We currently charge $35 for missed appointments. A missed appointment is defined as an appointment that is not rescheduled or cancelled prior to 24 hours of the appointment. It is your responsibility to call during business hours to cancel or reschedule prior to your appointment. Repeated “no shows” may result in the patient and family members being discharged from the practice.

WHAT TO EXPECT

The first visit will include a thorough review of your medical history. Please plan to arrive 15 minutes before your appointment time, no earlier than 8 am though, so our staff can complete your registration. For new patients the doctor will perform a comprehensive eye exam, which almost always includes dilation of the pupils. You will first be seen by an Orthoptist or Technician, who will review the patient history and perform vision measurements before putting in dilating drops. The drops take up to 60 minutes to work, during which time you will wait in the waiting room. We offer free Wi-Fi in the waiting room and movies for the children. The doctor will then complete the refraction test and exam and discuss findings and recommendations with you.

Your first appointment may take as long as two and a half hours or longer if emergencies arise, so please plan accordingly.

REFRACTION

It is important for you to understand what refraction is and why we perform it.

• Refraction is the part of the exam that determines whether or not correction is needed to improve the patient’s eyesight or eye alignment. Refraction is a critical portion of the eye exam. Without doing a refraction the doctor will be unable to determine whether problems such as eye misalignment, double vision, headaches, blurry vision, eyestrain, or a failed vision screening can be helped with corrective lenses, or with a change in current corrective lenses.
• It is typically performed during every complete eye exam, and periodically as needed, usually once per year.
• It is required in order to write an eyeglass or contact lens prescription. Note that in some cases the refraction shows that corrective lenses are not needed, or that the current lenses do not need to be changed.

Refraction is not a medical covered service by most insurance plans, unfortunately. These plans consider refraction a “vision” service and not a “medical” service. Our fee for refraction is $50, the refraction this fee is collected at the time of service in addition to any co-payment required by your plan unless your plan covers it. If your plan should cover the refraction, we will reimburse you. You may also obtain a receipt and file a claim on your own with your vision plan for reimbursement.

SURGICAL PROCEDURES

Co-pays, coinsurance, and deductibles are the patient’s responsibility and are collected prior to the procedure. These payments will be handled by the Surgical Insurance Specialist. Please note that the facility and anesthesia charges are separate and will be billed separately by each entity.

REFERRAL AND AUTHORIZATIONS

It is the policyholder’s responsibility to obtain referrals required by your insurance carrier. You are responsible for charges not covered due to lack of required referrals and/or authorizations. If your plan requires an authorization to see a Specialist, please make sure that you have authorization prior to your appointment. Typical plans that require authorization are HMOs and Managed Care plans.

FINANCIAL POLICIES

Your insurance coverage is a contract between you and the insurance company, not between the insurance company and the doctor. It is your responsibility to know the details of your plan.

We will verify your benefits the day of each appointment. Full payment or co-payment as required by your insurance company is due at the time of service. If we are filing insurance, please provide a current card. If you do not have your current insurance card, we may reschedule your appointment or you may be seen as a private pay patient. We accept cash, personal check, Visa, Mastercard, Discover, American Express and Care Credit. If your check is returned for any reason, you will be charged a $35 processing fee in addition to the delinquent payment.

If your account is past due, you may be referred to a collection agency, and you may be required to pay the past due amount in full before any additional services are rendered.

PLEASE NOTE THAT WE DO NOT PARTICIPATE WITH VISION PLANS, WE ARE A MEDICAL PRACTICE.

If you have any questions, please contact Kevin Primeaux, Administrator, Kevin@kidseyes.net or 210-340-6633, Ext 8. For weather changes/delays or other information, please check our Facebook page.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Demographics

Please fill out all information

List of other persons allowed access to patient's medical eye information (step-parents, grandparents, siblings, caretaker, etc..)

Please list any Primary Care Physician that may require a letter for your visit with us

Insurance Coverage (ID Card required)

Refraction Fee

A Refraction test determines whether or not your child needs glasses, and how strong they should be. Some insurance companies cover this test, but most do not. If your insurance does not cover the refraction fee, you will be responsible for this portion of the bill in addition to your co-payment.

To the best of my knowledge, the above information is correct, and I hereby authorize Children's Eye Center of South Texas, PA to release medical information to my insurance company. I authorize payment of surgical and/or medical benefits directly to Children's Eye Center of South Texas, PA. I understand that I am financially responsible for all charges not covered by this authorization, and I hereby guarantee payment of this account to 1439 E. Sonterra San Antonio, TX 78258. I authorize release of all medical records requested by Children's Eye Center of South Texas, PA.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

ADULT MEDICAL HISTORY QUESTIONNAIRE - OPHTHALMOLOGY

PLEASE MARK ALL THAT APPLY. THINGS YOU ARE BEING TREATED FOR, OR HISTORY OF.

Review of Systems: (Please mark all that apply)

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Notification of Office Policy

Dear Patients:
Weekly, our office has 45 (forty-five) patients miss appointments.
That means:

Weekly, 45 times our staff spent time on the phone to make the appointment.
Weekly, 45 times our staff called to remind patients of their coming appointment.
Weekly, 45 times our staff had to call an insurance company to verify coverage.
Weekly, 45 times our staff had to pull the chart.
Weekly, 45 times our staff had to review what the patient was coming in for.
Weekly, 45 times computer memory was used.
Weekly, 45 times our staff had to make a note on the computer of the missed appointment.
Weekly, 45 times the doctor had to review the chart to notify the patient of a missed appointment.
Weekly, 45 times our staff had to file paper inside the patient's chart.
Weekly, 45 times our staff had to mail out missed appointment information.
Weekly, 45 times our staff had to file a chart away.
Weekly, 45 patients have to wait that much longer for their appointment.

Therefore:

All missed appointments and cancellations with less than 24 hours notice will be charged $35. You will need to pay the $35 before a new appointment can be made. Insurance DOES NOT pay for this.

Medical forms brought in at the time of your appointment or after will be filled out within 10 business days.

Return to school/work and prescriptions requested after your appointment will be processed with 48 hours from the day you call.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.