NEW PATIENT REGISTRATION FORM

  • I give Twenty Twenty Eyecare permission to disclose or obtain any medical or financial information to/from the following:

  • Notice of Privacy Practices

    I acknowledged that I have read or have been given the opportunity to read Twenty Twenty Eyecare’s Notice of Privacy Practices (available at the front desk)
  • Typing your name above acts as your digital signature
  • Insurance Information

  • If you are using insurance, we need a copy of your medical and vision cards. We treat both medical eye problems as well as vision care.

    Vision Plans Vision plans usually include benefits towards glasses and contact lenses. Medical insurances generally do not cover these benefits but will help pay for your visit with the doctor. Medicaid (Soonercare) only allows glasses for patients less than 20 years of age and they do not cover contact lenses unless medically necessary. Medical Insurance Checking vision (refraction) and contact lenses are not generally covered by medical insurances. We can file your medical insurance on your behalf but this does not guarantee payment from your insurance. You will be responsible for any balance not paid by your insurance. If your deductible has not been met for the year, you will be responsible for medical services rendered. Medical services include eye infections, eye diseases, dry eye, foreign body removals from the eye and eyelids, etc. Retinal Photos We will be taking pictures of the back of your eye (retina). It is very important to have retinal photo documentation. Many disease of the retina are diagnosed by change over time. As doctors we do the best we can to record all findings. However, nothing is as accurate as a photo. Unfortunately, medical insurances do not pay for this technology. The cost to the patient is only $25. I authorize you to bill my insurance for any applicable services or products, and I understand that payments for non-insured services are due the same day as service and that I may be billed for the remaining balance after insurance has been filed. This includes the cost of retinal photos.
  • Typing your name above acts as your digital signature.
  • Review of Systems