PATIENT INFORMATION

Authorization For Benefits and Medical Release and Acknowledgment of Privacy Practice I authorize insurance payments directly to Laramie Peak Vision, LLC. I further authorize the release of any information necessary to process claims on my behalf. I understand and agree that I am financially responsible for any charges incurred by me or any family members regardless of insurance. I further understand that any legal fees or interest charges from collection of these fees shall be my responsibility. I acknowledge thatI have received a copy of Laramie Peak Vision, LLC Notice of Privacy Practices related to HIPAA.

I request the following people have access to my medical information:

Laramie Peak Vision, LLC

Patient Medical History

Name of Primary Care Doctor:

Please check any conditions that apply to you:

Hemotologic/Lymphatic

MusculoImmune Systemskeletal

Are you pregnant or nursing?

Yes No

Are you allergic to any medications?

Yes No

If yes, please list the medications:

Please list any other allergies (food, environmental, etc.

Have you ever experienced or been diagnosed with any of the following? (Please check all that apply)

Do you use:

Alcohol Tobacco Smoke/IV Drug Use Former Smoker

Current Medications (Rx or Over the Counter) Please list any medications you are currently using. If you take more than the area provided, please provide a list for us to copy.

Family Medical and Eye History Please note who of your Parents, Siblings, or Children have any of the following:

Other Significant Family History (please specify)

Payment is expected at time of service. ● Divorce Parents: We are not a party to the divorce agreement. Both parents are responsible for vision/medical bills of minor children. ● We file claims with most insurance companies provided we have current insurance information, including a copy of the insurance card. ● Payment of half down and the balance at pick up is required on all orders. ● Copays and deductibles are due at the time of service. ● Balances over 30 days are assessed a finance charge of 18% APR (1.5% per month). ● Following 90 days of nonpayment (and LPV attempts to collect), past due accounts will be turned over to collections. ● Returned checks are subject to a $30.00 NSF fee and applicable postage and legal fees. ● Patients are responsible for any emergency fees incurred, even if the insurance denies payment. ● Previous collections or NSF check accounts: Any future appointments require the balance to be paid in full at the time of the exam and/or material’s purchase with cash or credit card.

I hereby acknowledge that I have read, understand, and agree to all of the terms and conditions listed above.

Laramie Peak Vision Financial Policy HIPAA Acknowledgement

We are committed to providing you with the best possible care, and we are available to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions regarding our fees, financial policy, or your responsibility. All services and special order items including prescription glasses and sunglasses are non-refundable. We accept cash, check, Visa, and Mastercard for your convenience and expect payment when services are rendered. As a courtesy we will file your insurance claim for you as long as you provide all the required information. For example: copy of all insurance cards, insured’s social security number, insured’s date of birth, and the insured’s employment information are all required. I understand and agree that I am ultimately responsible for the balance of my account for any professional services rendered including but not limited to charges incurred from any and all exams, office visits, additional testing, contact lens fits, contact lens boxes, or glasses and glasses repairs of any kind regardless of having insurance or not. If I choose to not pay any outstanding balance, I could be responsible for court costs and attorney’s fees, and interest charges of 1.5% monthly on any outstanding balance not paid that is sent to small claims court. In the event of collection procedures, attorney fees and court costs are my responsibility. I also understand that the delinquency fee with regards to collections will be equal to 50% of the principal amount owed. I authorize the release of medical information or any other information as needed to submit an insurance claim for myself or any other dependent child with whom I have financial responsibility for. I authorize the use of the signature below on all insurance submissions. I authorize the payment of insurance benefits to Laramie Peak Vision. Patients under the age of 18 should be accompanied by a parent or legal guardian. The parent who signs the financial policy form is responsible for payment of services. In the event the minor comes unaccompanied to our office, we MUST have a signed authorization for treatment form as well as payment services rendered. I hereby acknowledge that I have received and/or read a copy of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Policy. I certify that I have read and understand the financial and HIPAA Privacy Policy of Laramie Peak Vision

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