Patient Registration Form

ASSIGNMENT & RELEASE / MEDICARE AUTHORIZATION 
I, the undersigned, certify that I or my dependant have insurance coverage with

and assign directly to Rogers Regional Eye Center ("The Clinic") all insurance benefits, if any, otherwise payable to me for services rendered. I understand I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize use of this signature on all insurance submissions. I also certify that all medical information provided on the front and back of this page is true and accurate to the best of my knowledge. 
If applicable, I request payment of authorized Medicare benefits be made on my behalf to The Clinic for services furnished to me by The Clinic. I authorize any holder of medical information about me to release to The Center for Medicare and Medicaid Services and its agents any information needed to determine those benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If "other health insurance" is indicated in item 9 of the CMS-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge. Coinsurance and deductibles are based upon the charge determination of the Medicare carrier.

PATIENT CONSENT FOR TREATMENT & AUTHORIZATION TO RELEASE MEDICAL INFORMATION FOR ASSIGNMENT OF HEALTH INSURANCE BENEFITS 
Our Notice of Privacy Practices provides information about how we may use and disclose protected health insurance about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our Office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that statement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The patient understands that:
 
* Protected health information may be disclosed or used for treatment, payment or health care operations.

* The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.

* The Practice reserves the right to change the Notice of Privacy Policies.

* The patient has the right to restrict the uses of their information but the practice does not have to agree to those restrictions.

* The patient may revoke this Consent in writing at any time and all future disclosures will then cease.

* The Practice may condition treatment upon the execution of this Consent.
 
I further acknowledge that I will be responsible for the payment of all charges for professional services and/or goods received regardless of whether or not I have insurance coverage.