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Medical Release Form

Innovation Optometry PC

Better Sight is Our Shared Vision
  • 2001 South Road
    Poughkeepsie, NY 12601
  • Phone: (845) 296-0291
    Fax: (845) 296-0432
  • Record Release

  • By signing below, I understand that I will allow Innovision Optometry PC to copy and/or release my medical records, should the need arise, to any HIPPA compliant agency on my behalf, including LensCrafters associates and management, with only my full knowledge in the form of a verbal or written request that such a transaction take place. I then release Innovision Optometry PC from any and all state or federal statutes relating to patient privacy.
  • For Patients Using Medical Insurance

  • I understand that Refraction is not considered a “medical service”, but a “vision service” and Medicare and medical insurance carriers do not cover this service. I agree to pay the office fee of $35.00 for this service. I understand that refraction may be billed to my insurance as a courtesy and should my plan pay in part or in full, I will be granted a refund for the total amount.

    By signing below, I indicate that my consent has been given to the staff of Innovision Optometry PC to verify that I have insurance coverage through:

  • and further consent to having all benefits and coverage details communicated to any and all parties involved with the above named insurance.

    Any information gathered that applies to my insurance coverage and benefits for eye exam fees and any additional medical testing, by signing below, I hereby give consent that they be utilized for the medical billing procedures at Innovision Optometry PC.
  • Assignment of Benefits and Signature on File

  • I understand my signature below requests that payment be made to Innovision Optometry PC and/or their providing doctors by the above named insurance carrier and authorizes the release of any medical information necessary to pay the claim. It is my responsibility to determine physician participation in my plan, coverage applicable, co-pays and any other requirements of my insurance policy for services rendered at Innovision Optometry PC. I am responsible for the deductible, coinsurance, co-pay, and services that are not covered.

    For Medicare, I request that payment of authorized Medicare benefits be made on my behalf to Innovision Optometry PC and their providing doctors for services rendered. I authorize any information needed to determine benefits or the benefits payable for these services are released to the Centers for Medicare and Medicaid Services and its agents. Innovision Optometry PC accepts the charge determination of the Medicare carrier as the full charge and I am responsible only for the deductible, coinsurance, and services that are not covered. Coinsurance and deductible are based upon the charge determination of the Medicare Carrier.

    I understand that my signature below authorizes the above statements be commenced as of the date below.
  • Financial Policies and Patient Agreement

  • I agree that in return for the services provided to the patient by Innovision Optometry PC, I will pay my account at the time services are rendered. I understand Innovision Optometry PC contracts with health care service plans to only perform services that are “covered” by the carriers and their plans.

    The undersigned accepts full financial responsibility for any non-covered services, co-pays, deductibles, coinsurance or unauthorized services. If my account is sent to a collection agency, I agree to pay collection expenses and reasonable attorney’s fees as established by the court and not by a jury in a court action. It is understood that the undersigned and/or the patient are primarily responsible for the payment of my bill.

    With regards to minor patients, I understand that as the parent/guardian accompanying the patient, I will be fully responsible for payment of services rendered at Innovision Optometry PC.

    With regards to Contact Lenses, I understand that in most cases medical insurance does not cover the cost of the contact lens evaluation, prescription verification or fitting. The charge for these contact lens services is a separate and additional charge to the eye exam. I understand that the Contact Lens prescription must be done every calendar year and I am not authorized to purchase any supplies until I provide proof that the evaluation has been done elsewhere or make an appointment with Innovision Optometry PC to have the service.

    With regards to Returned Checks, any payment made by check that does not clear your bank account will result in a fee for insufficient funds. Our fee for insufficient funds is $25.00 and will be added to your account with each returned check. I understand that my signature on this statement authorizes Innovision Optometry PC to engage this policy should it apply to my patient account.

    In addition, any fees including co-pays, which have not been paid at time of service, by signing this agreement, I understand that my prescription(s) will not be dispensed until payments are made.
  • Collection of Medical Fees for Private Pay

  • By signing this statement, I indicate that I consent to pay at time of service, any medical fees consistent with what is not covered by my medical insurance. I further indicate that this collection procedure has been explained in full by the staff at Innovision Optometry PC. In addition, any fees including co-pays, that have not been paid at time of service, by signing this statement, I understand that my prescription(s) will not be dispensed until payments are made.