Online Patient Forms

Financial Policy, Privacy & Consent

Please read the policies supplied in the patient registration packet before submitting.

Financial Policy

To better serve our patients and keep costs to a minimum, our office maintains the following financial policy. Accepted forms of payment due at the time of service include cash, check ($35 returned check fee), credit card, flex spending card and/or care credit. As a courtesy Epic Vision Eye Centers will file your vision or medical claim on your behalf. You will be responsible for any balance that your insurance policy does not cover. Account balances are due 30 days after the mailing of your outstanding balance statement. Accounts more than 90 days past due may be referred to our collection agency and will include a 15% collection fee. If overpayment or underpayment occurs, Epic Vision Eye Centers reserves the right to maintain the balance on the account to be collected or used on a future visit.

Privacy & Consent Policy

While providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information to treat you, to obtain payment for our services and to conduct health care operations involving our office. The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. You are free to refer to this notice at any time before you sign this form. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and service provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes (1) our submission of your health information to a billing agent or vendor for processing claims or obtaining payment; (2) our submission of claims to third-party payers or insurers for claims review, determination of benefits and payment; (3) our submission of your health information to auditors hired by third-party payers and insurers; and (4) other aspects of payment described in our Notice of Privacy Practices. Our Notice of Privacy Practices will be updated whenever our privacy practices change. You can get an updated copy here at the office. When you sign this consent document, you signify that you agree that we can and will use and disclose your health information to treat you, to obtain payment for our services and to perform healthcare operations. You also signify that you have received a copy of our Notice of Privacy Practices. You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment, or healthcare operations, but as described in our Notice of Privacy Practices, we are not obliged to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction. I certify that the information given by me in applying for insurance and/or Medicare payment is true and correct. I authorize my doctor to act as my agent in helping me obtain payment of my insurance and/or Medicare benefits, and I authorize payment of these benefits directly to Epic Vision Eye Centers on my behalf for any services and materials furnished. 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 these benefits payable to related services. If I have other health insurance coverage (as indicated in Item 9 of the CMS-1500 claim form or electronically submitted claim), my signature authorizes release of the above medical information to the insurer or agency shown and authorizes my doctor to act as my agent as above. I have read this document and understand it. I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations. I acknowledge that I have received the Notice of Privacy Practices from Epic Vision Eye Centers.

Signature on File

Signatures are required by patient/representative when Epic Vision Eye Centers will be billing the patients’ insurances.

MEDICARE/ADVANTAGE: I request that payment of authorized Medicare benefits be made on my behalf to Epic Vision Eye Centers for services furnished to me by any Epic Vision Eye Centers Doctor. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable to 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 HCFA 1500 form or elsewhere on other approved claim forms, my signature authorizes releasing the information to the insurer or agency shown. Epic Vision Eye Centers accepts the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.

OTHER: I hereby authorize payment of my medical and surgical insurance benefits to Epic Vision Eye Centers. I understand I am financially responsible for any charges whether or not paid by said insurance. If copayments and/or deductibles are designated by my insurance company or health plan I agree to pay them to Epic Vision Eye Centers. I authorize Epic Vision Eye Centers to release any information required to process any and all claims for reimbursement on my behalf. A copy of this authorization may be used in place of the original.

A parent/legal representative is required for patients under 18. This typed acknowledgment is not a verified electronic signature; the office may request a signed copy of the authorizations.

Patient packet version: 7/2026.