Consents

Acknowledgement of Notice of Privacy Practices
The law requires Hinsdale Advanced Eye Care make every effort to inform you of your rights to your personal health information. By my signing below, I acknowledge that:
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I have read or had explained to me Hinsdale Advanced Eye Care's Notice of Privacy Practices and agree to continue my care with Hinsdale Advanced Eye Care under said terms. I was given the opportunity to read Hinsdale Advanced Eye Care's Notice of Privacy Practice and declined but wish to continue my care with Hinsdale Advanced Eye Care under the terms of Hinsdale Advanced Eye Care's privacy policies. I have read or had explained to me Hinsdale Advanced Eye Care's Notice of Privacy Practices and do not wish to continue my care with Hinsdale Advanced Eye Care under said terms. The Notice of Privacy Practices could not be read due to the emergent nature of the care.
I have read and understand this form. I am signing it volunterily.
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If you are signing as a personal representative of the patient, please indicate your relationship.
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Insurance
There are two types of health insurance that may help pay for services and products at Hinsdale Advanced Eye Care. You may have one or both.

1. Vision Insurance: Vision care plans cover ONLY routine/ healthy vision exams. They may also cover materials such as glasses or contacts.

2. Medical Insurance: Medical care plans cover the treatment and management of eye diseases and screening for eye diseases if you have certain systematic conditions.

If you have both types of insurance, it may be necessary for us to bill some services to one plan and other services to the other. We will coordinate benefits to minimize your out-of-pocket expenses as healthcare guidelines allow.

We will bill your insurance plan for services and products if we are a participating provider. We make every attempt to obtain advanced authorization of your insurance benefits. We do need information from you to obtain authorization. You will be financially responsible if some fees are not paid for by your insurance plan, such as: deductibles, co-pays, and non-covered services.
My signature authorizes the release of health information to the insurer. If I decline to sign, I understand that I am solely responsible for all fees, which are due at the end of time of service.
Contact Lens Services
Please be advised that when being examined for contact lens wear there are additional evaluation fees that may not be covered in full by your insurance provider. In those cases, it becomes the patient’s responsibility.
Patient Name *

First Name Last Name
Signature of Patient or Legal Guardian *

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Acknowledgement of Notice of Privacy Practices

Insurance

Contact Lens Services