Insurance #1 (Primary Insurance- This will be filed first)
Insurance #2 (Secondary Insurance-This will be filed after primary insurance pays)
Insurance #3 (Tertiary insurance- This will be filed after primary and secondary insurance pays)
Initial in the boxes.
After 2 no call-no show appointments, it will be documented in the patient’s chart and a fee of $50 will be assessed to the patient’s account and may ultimately result in dismissal from our practice.
Best possible vision measurement or RX. This is a medically non-covered service. The fee is $40.00 and is collected at time of service. We only collect if service is performed.
I have reviewed the Notice of Privacy Practices as provided at registration and understand that I may request a copy of the policy at any time.
I hereby authorize Dr. Kassels, Dr. Lenz and/or such assistants as may be designated by him/her to administer dilating eye drops. The eye drops are necessary to diagnose my condition. We recommend a driver.
I consent to treatment at Tennessee River Eye Clinic and my consent remains effective until revoked in writing by me. You have the right at any time to discontinue services.
I authorize the release of any medical information necessary to process a claim on any insurance policy on file. I hereby assign to and authorize payment directly to Tennessee River Eye Clinic/Mark Kassels M.D./Jan Lenz O.D. of all benefits payable under Medicare, Medicaid or other insurance policy as well as any MEDIGAP Insurance. I understand that I am ultimately responsible for all charges, whether or not paid by my insurance. I also understand that, should I default on my account, all costs of attorney's fees, interest and cost of collections would be my responsibility.
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.
Release of Information To Family/Friends Authorization
Only complete the name/dob/ssn/signature and date.
I authorize Tennessee River Eye Clinic to release my information to the following individuals: