Ranch
Blvd.
Ste.
50
114
Mission Ranch
Blvd.
Ste.
50
7056
Skyway
114
Ranch
Blvd.
Ste.50
50
114
Mission
Ranch
Blvd.
Ste.
320
HMission
Street,
Suite
4
Paradise,
California
95969
Chico,
CA
95926
95926
Chico,
CA
95926
Chico,
CA 95926
Marysville,
CA 95901
Phone
(530)
877-2250
Ph
530-891-1900
Fax
530-895-1531
530-891-1900
Fax
530-895-1531
FaxPh
(530)
877-1264–––––Fax
Ph
530-891-1900
Fax
530-895-1531
Ph
530-891-1900
530-895-1531
530-743-1873
Fax
530-743-1460
PATIENT
PATIENT
DEMOGRAPHICS
PATIENT
DEMOGRAPHICS
DEMOGRAPHICS
PATIENTDEMOGRAPHICS
DEMOGRAPHICS
PATIENT
Patient
Name:
___________________________________________________________________
Sex:
Patient
Name:
___________________________________________________________________
Sex:
M FF
Patient Name:
Name: ___________________________________________________________________
___________________________________________________________________ Sex:
Sex: M
Patient
MM FF
Home
Phone:
(______)
__________________________
Cell
Phone
(_____)
_____________________________
Home
Phone:
(______)
__________________________
Cell
Phone
(_____)
_____________________________
Home Phone:
Phone: (______)
(______) __________________________
__________________________ Cell
CellPhone
Phone(_____)
(_____)_____________________________
_____________________________
Home
Mailing
Address:
_______________________________
City:
_____________________
State/
Zip:
__________
Mailing
Address:
_______________________________
City:
_____________________
State/
Zip:
__________
Mailing Address:
Address: _______________________________
_______________________________ City:
City:_____________________
_____________________State/
State/Zip:
Zip:__________
__________
Mailing
Soc.
Sec#:
____________________________________
DOB:
______________Status:
(circle)
S
M
DD
Soc.
Sec#:
____________________________________
DOB:
______________Status:
(circle)
S
M
WMinor
Minor
Soc.
Sec#:
____________________________________
DOB:
______________Status:
(circle)
S
M
D WW
Minor
Soc.
____________________________________
(NeededSec#:
for Medicare,
Medicare,
Medi-cal, patients
patients w/vision
w/vision insurance or students covered
(Needed
for
Medi-cal,
covered under
under parents
parents insurance)
insurance) DOB: ______________Status: (circle) S M D W Minor
(Needed
for
Medicare,
Medi-cal,
patients
w/vision
insurance
or
students
covered
under
parents
insurance)
(Needed for Medicare, Medi-cal, patients w/vision insurance or students covered under parents insurance)
E-Mail
Address:
_______________________________
E-Mail
Address:
_______________________________
E-Mail Address:
Address: _______________________________
_______________________________
E-Mail
Responsible
Party:
_____________________________
Relationship
to
Patient:
_________________________
Responsible
Party:
_____________________________
Relationship
to
Patient:
_________________________
Responsible Party:
Party: _____________________________
_____________________________
Relationshipto
toPatient:
Patient:_________________________
_________________________
Responsible
Relationship
Employed
by:
_________________________________
Employed
by:
_________________________________
Employed by:
by: _________________________________
_________________________________
Employed
Address:
_____________________________________
Address:
_____________________________________
Address: _____________________________________
_____________________________________
Address:
Employer
Phone:
______________________________
Employers
Phone:
______________________________
EmployersPhone:
Phone:______________________________
______________________________
Employer
City/State/Zip:
_________________________________
City/State/Zip:
_________________________________
City/State/Zip:_________________________________
_________________________________
City/State/Zip:
Family
Physician:
______________________________
Family
Physician:
______________________________
Family Physician:
Physician: ______________________________
______________________________
Family
Emergency
Contact:
____________________________
Emergency
Contact:
____________________________
Emergency
Contact:
____________________________
Emergency Contact: ____________________________
Emergency
Contact
Phone:
_____________________
Emergency
Contacts
Phone:
_____________________
Emergency Contact
ContactsPhone:
Phone:_____________________
_____________________
Emergency
Family
Physician
Phone:
________________________
Family
Physician
phone:
________________________
FamilyPhysician
PhysicianPhone:
phone:________________________
________________________
Family
Relationship:
_________________________________
Relationship:
_________________________________
Relationship:
_________________________________
Relationship: _________________________________
ONE)
□
VSP
□
MES
□
EYE
MED
□ Principal
□ NVIH
Vision Plan
Plan Coverage
Coverage Information:
Information: (CIRCLE
(CIRCLE
ONE)
□
VSP
□
MES
□
EYE
MED
Principal
NVIH
Vision
(CIRCLEONE)
ONE) □
□VSP
VSP □
□MES
MES □
□EYE
EYEMED
MED □□
□Principal
Principal □□
□NVIH
NVIH
Vision Plan
Plan Coverage
CoverageInformation:
Information: (CIRCLE
Vision
Policy
Holder:
________________________________
DOB:
____/____/______
SS#:___________________
Policy
Holder:
________________________________
DOB:
____/____/______
SS#:___________________
Policy
Holder:
________________________________
DOB:
____/____/______
SS#:___________________
Policy Holder: ________________________________ DOB: ____/____/______ SS#:___________________
Medical Insurance
Insurance Information:
Information:
Medical
Medical Insurance
Insurance Information:
Information:
Medical
Primary: ________________________________
________________________________
Primary:
Primary: ________________________________
________________________________
Primary:
Policy Holder:
Holder: ____________________________
____________________________
Policy
Policy Holder:
Holder: ____________________________
____________________________
Policy
Date
of
Birth:
____________________________
Date
of
Birth:
____________________________
Date
of
Birth:
____________________________
Date of Birth: ____________________________
SS#: ___________________________________
___________________________________
SS#:
SS#: ___________________________________
___________________________________
SS#:
ID#:
___________________Group#:
_________
ID#:
___________________Group#:
_________
ID#: ___________________Group#:
___________________Group#:_________
_________
ID#:
Relationship:
Self
Spouse
Parent
Relationship:
Self
Spouse
Parent
Relationship:
Self
Spouse
Parent
Relationship: Self
Spouse Parent
Other __________
__________
Other
Other__________
__________
Other
Ridge Eye Care, Inc.
Secondary:
_____________________________
Secondary:
_____________________________
Secondary:_____________________________
_____________________________
Secondary:
Policy
Holder:
___________________________
Policy
Holder:
___________________________
Policy Holder: ___________________________
Date
of
Birth:
___________________________
Date of
ofBirth:
Birth:___________________________
___________________________
Date
SS#:
_________________________________
SS#:
_________________________________
SS#: _________________________________
ID#
______________Group#:______________
ID# ______________Group#:______________
______________Group#:______________
ID#
Relationship:
Self
Spouse
Parent
Relationship: Self
Self Spouse
Spouse Parent
Parent
Relationship:
Other
__________
Other
__________
Other __________
ASSIGNMENT OF BENEFITS
ASSIGNMENT
OF
BENEFITS
OFBENEFITS
BENEFITS
ASSIGNMENT
IASSIGNMENT
understand that OF
North
Valley Eye Care will bill my medical insurance carrier for covered services.
understand
that
Royo
Eye
Care
will
bill
my
medical
insurance
carrier
for
services.
Iunderstand
understand
that
Ridge
Eye
will
billwill
my
medical
insurance
carrier
forcovered
covered
services.
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that
North
Eye
Care
bill
my insurance
medical
insurance
carrier
forbe
covered
North Valley
Eye
CareValley
is
notCare
contracted
with
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plan,
payment
will
due
atservices.
the time of service, and I will be provided with an itemized
IfIfNorth
Royo
Eye
Care
isisCare
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contracted
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payment
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time
service,
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with
itemized
statement
Ridge
Eye
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with
If
Valley
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time
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be provided
with
an itemized
statement with which I can bill my insurance carrier.
which
I canwith
bill
my
which
billwhich
my insurance
insurance
carrier.
statement
I can
billcarrier.
my
insurance
carrier.
 I Ican
authorize
and
request
that
insurance
benefits be made directly to North Valley Eye Care on my behalf for all services furnished to me by any
authorize
and
request
that
insurance
benefits
be directly
made
to Royo
Eye
Care
on
my
to me
meby
byany
any
Iauthorize
authorize
andrequest
request
that
insurance
benefits
Ridge
Eye
Care
onon
my
behalf
for
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 IIphysician
and
that
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mybehalf
behalffor
forall
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employed
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their
affiliates.
physician
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or
its
affiliates.

I am aware that I am responsible for the deductible, coinsurance and any non-covered services. Coinsurance and deductibles are based upon
am
aware
that
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 IIthe
aware
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determination
of my insurance
carrier/carriers.
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change
determination
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insurance
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the
change
determination
of
my
insurance
carrier/carriers.
the
change
determination
of
my
insurance
carrier/carriers.

If I do not have insurance I understand that payment will be due at the time of service.
IfIfIIIdo
do
not
have
insurance
understand
that
payment
will
be
due
at
the
time
of
service.
donot
nothave
have
insurance
understand
thatpayment
payment
willbe
bewhether
dueat
atthe
the
timepaid
ofservice.
service.
 If
insurance
IIIunderstand
that
will
due
of
I understand
that
I am financially
responsible
for all charges
or time
not
by my insurance.
 IIIunderstand
understand
that
am
financially
responsible
for
all
charges
whether
or
not
paid
by
my
insurance.
understandthat
thatIIIam
amfinancially
financiallyresponsible
responsiblefor
forall
allcharges
chargeswhether
whetheror
ornot
notpaid
paidby
bymy
myinsurance.
RELEASE OF INFORMATION
RELEASE
OF
INFORMATION
RELEASEauthorization,
OFINFORMATION
INFORMATION
RELEASE
OF
Insurance
release of medical records, insurance benefits and assignments, responsibility of patient and acknowledgement
Insurance
authorization,
release
of
medical
records,
insurance
benefits
and
assignments,
responsibility
patientand
andacknowledgement
acknowledgement
Insurance
authorization,
release
ofmedical
medicalrecords,
records,
insurance
benefits
andyour
assignments,
responsibility
Insurance
authorization,
insurance
and
assignments,
responsibility
ofofpatient

North
Valley Eyerelease
Care, of
employees
of
its Medical
staffbenefits
(including
physician),
and the independent
contractor
services have agreed, as
Royo
employees
ofofits
Medical
staff
your
physician),
and
the
independent
contractor
services
have
agreed,
as
permitted
RidgeEye
EyeCare,
Care,
employees
itshealth
Medical
staff(including
(including
your
physician),
andpurposes
the and
independent
contractor
services
 North
Valley
Eye
Care,
employees
of its
Medical
staff
(including
your for
physician),
the
independent
contractor
services
have
agreed,
as
permitted
by
law,
to share
your
information
among
themselves
the
of treatment,
payment
or health
care
operations.
This
by
share
your
health
information
among
for
the
of
treatment,
payment
orpayment
care
operations.
This of
enables
by law
law to
tous
share
your
health
information
among
themselves
for
the purposes
purposes
of
treatment,
us
permitted
by
to share
your
health
information
among
themselves
for isthe
purposes
of treatment,
or health
careNotice
operations.
This
enables
tolaw,
better
address
your
health
care themselves
needs.
This
information
being
provided
to you as
ahealth
supplement
to The
Privacy
enables
to better
your
health
This
information
is being
provided
to
as care
atosupplement
Notice
of release
Privacy
to
address
health
care
needs.
This
information
is
being
provided
to
as
The
Notice to
ofI The
Privacy
Practices
given
to better
betterus
address
your
health
care
needs.
Thisneeds.
information
is
beingof
provided
to you
you
as a supplement
Practices
given
to your
youaddress
by
North
Valley
Eyecare
Care.
For the
purposes
treatment,
payment,
or you
health
operations,
authorize
the
Practices
to
you
by North
Valley
Eyeinformation
Care.
Forbetween
the purposes
treatment,
payment,
or health
care
operations,
I insurance
authorize
the release
to
by
Royo
Eye
Care.
For
the
of
payment,
or
care
operations.
authorize
the
of all medical
records
to you
youmedical
bygiven
Ridge
Eye
Care.
For
thepurposes
purposes
oftreatment,
treatment,
payment,
or health
health
care
operations.
authorize
the release
release
, IImy
of
all
records
and
any
insurance
NorthofValley
Eye Care,
its affiliates,
family
physician,
carriers
and
of
allHealth
medical
records
and any
insurance
between
North
Eye
Care,
its affiliates,
my family
physician,
carriers
and
and
any
insurance
information
between information
Ridge
Eye Care,
Care,
its
affiliates,
my family
family
physician,
insurance
carriers
Financing
and
any
insurance
information
between
Royo
Eye
its
my
physician,
insurance
carriers
and theinsurance
Health Care
the
Care
Financing
Administration
to
process
claims
foraffiliates,
relatedValley
services.
the
Healthauthorize
Careto
Financing
Administration
to information
process
for related
services.
to
process
claims for
forrelease
related
services.claims
Administration
process
claims
related
services.

IAdministration
hereby
said assignee
to
necessary
to secure
payment.
hereby
authorize
saidassignee
assignee
torelease
releasesubmission
information
necessary
tosecure
securepayment.
payment.
authorize
said
assignee
to
release
information
necessary
to
secure
payment.
 IIIhereby
authorize
said
to
information
to
allow
for
fax transmission
and electronic
ofnecessary
such information.
I allow
allow
forfax
faxtransmission
transmission
and
electronic
submission
ofsuch
suchinformation.
information.

IA
fax
transmission
and
electronic
submission
of
such
information.
submission
of
scan for
and/or
photocopy
ofand
thiselectronic
assignment
will be considered
as valid as an original.
scanand/or
and/orphotocopy
photocopyof
ofthis
thisassignment
assignmentwill
willbe
beconsidered
consideredas
asvalid
validas
asan
anoriginal.
original.
and/or
photocopy
of
this
assignment
will
be
considered
as
valid
as
an
original.
 AAscan
CONSENT FOR TREATMENT
FOR
TREATMENT
CONSENT
FOR
TREATMENT
TREATMENT
ICONSENT
have read
and
fully understand the above consent for evaluation and treatment, financial responsibility, release of medical
I have
have read
readand
and
fully understand
understand
the above
above consent
consent for
for evaluation
evaluation and
and treatment,
fully
understand
the
above
consent
for
evaluation
and
treatment, financial
financial responsibility,
responsibility, release
release ofof medical
medical
Iinformation
and
fully
the
insurance
authorization.
informationand
andinsurance
insuranceauthorization.
authorization.
insurance
authorization.
information
______________________________________________
______________________________________________
______________________________________________
______________________________________________
Signature of Patient / Parent / Guardian / Conservator
Signature of
of Patient
Patient // Parent
Parent /// Guardian
Guardian///Conservator
Conservator
Parent
Guardian
Conservator
Signature
___________
___________
___________
___________
Date
Date
Date
__________________________
__________________________
__________________________
__________________________
Reason
patient is unable to sign
sign
Reasonpatient
patientisisunable
unabletotosign
Reason
If you are an established patient, we apologize for any inconvenience, however, we are required to obtain a signature for insurance purposes and
If
you
an
established
patient,
we
for
any
Ifupdate
you are
are
an
established
patient,
we apologize
apologize
for
any inconvenience,
inconvenience, however,
however, we
we are
are required
required to
to obtain
obtain a
a signature
signature for
for insurance
insurance purposes
purposes and
and
allan
patient
information
annually.
Thankfor
you!
Ifyou
youare
are
established
patient,
weapologize
apologize
for
anyinconvenience,
inconvenience,however,
however,we
weare
and
established
patient,
we
apologize
any
inconvenience,
however,
we
arerequired
requiredtotoobtain
obtainaasignature
signaturefor
forinsurance
insurancepurposes
purposesand
Ifupdate
established
patient,
we
any
allan
patient
information
annually.
Thankfor
you!
update all patient information annually. Thank you!
114 Mission Ranch Blvd. Ste. 50
Financial
Policy
Chico, CA 95926
Financial
Policy and
and Disclosure
Disclosure
114 Mission Ranch Blvd, Suite 50
114 Mission
Ranch 95926
Blvd, Suite 50
Chico,
California
Chico,
California
95926
Phone: (530)891-1900
Phone: (530)895-1531
(530)891-1900
Fax:
Fax:
(530)895-1531
PATIENT
DEMOGRAPHICS
Ph 530-891-1900 – Fax 530-895-1531
Patient Legal Name: _______________________________________________
DOB: ____________
PatientLegal
Name:
___________________________________________________________________
Sex: M
F
Patient
Name:
_______________________________________________
DOB: ____________
Ridge
Eye
Care,(______)
Home
Phone:
Phone
(_____)
_____________________________
As
we are
dedicated
toInc.
providing __________________________
the most efficient and reasonable eye health andCell
vision
care services
to you
and your family, our office feels that your
As
we
are
dedicated
to
providing
the
most
efficient
and
reasonable
eye
health
and
vision
care
services
to
you
your family,
office
feels
that Policy
your
understanding
of the financial
and disclosure policy is also an essential component
of the_____________________
care. Therefore, it isand
necessary
for State/
us our
to have
a Financial
Mailing Address:
_______________________________
City:
Zip:
__________
understanding
of
the financial
and disclosure
policy
is also anfor
essential
component
of the
care. Therefore,
it is necessary for us to have a Financial Policy
and
Disclosure
statement
to
inform
you
of
our
requirements
payment
for
Services
provided
to
patients.
Soc.
Sec#: statement
____________________________________
DOB:provided
______________Status:
(circle) S M D W Minor
and
Disclosure
toatinform
you Care
of our requirements
for
payment
for
Services
to patients.
All
comprehensive
examspatients
Royo
Eye
includes
Diabetic
Exams)
consist of a full
eye health evaluation, which includes assessment for
(Needed
for Medicare, Medi-cal,
w/vision
insurance (which
or students
covered under
parentsEye
insurance)
All
comprehensive
exams
Eye Care
(whichthe
includes
Eye Exams)
consist
a full considered
eye health evaluation,
which includes
assessment
glaucoma
and cataracts
andataRidge
refraction
to evaluate
visual Diabetic
system. Refraction
Service
is of
usually
a “non-covered”
service with
most for
E-Mail Address:
_______________________________
glaucoma
and cataracts
and a refraction
to evaluate
visual system.
Refraction
usually considered
a “non-covered”
service
withand
most
medical insurances.
A Contact
Lens Evaluation
is anthe
optional
“non-covered"
by Service
medicalisinsurance
service which
is an additional
charge
may be
Responsible
Party:
_____________________________
Relationship
to
Patient:
_________________________
insurances.
A
Contact
Lens
Evaluation
is
an
optional
“non-covered"
by
medical
insurance
service
which
is
an
additional
charge
and
may be
medical
performed on the same day or within thirty (30) days of the routine eye exam.
performed on the same day or within thirty (30) days of the routine eye exam.
Employed
by:Vision
_________________________________
Employer Phone: ______________________________
Medical
and
Insurance Policy
Medical
Vision
Insurance
•Address:
If you carryand
a medical
insurance
policy, it Policy
is our policy to file a claim with yourCity/State/Zip:
insurance carrier as _________________________________
a courtesy to you. We must have accurate and
_____________________________________
• complete
If you carry
a medical
insuranceatpolicy,
it isofour
policy to file a claim with your insurance carrier as a courtesy to you. We must have accurate and
insurance
information
the time
service.
insurance
information
the timeby
of your
service.
• complete
If a service
is provided
and is notatcovered
insurance company, you will be expected to pay at the time of service.
Physician:
Phone:
••Family
If
is provided
and
is not covered
by your
insurance
company,
willFamily
be expected
towill
pay be
at the
time of________________________
service.
If aweservice
have
not
received______________________________
a payment
from your
insurance
company
withinyou
ninety
(90)
days,Physician
you
responsible
for the balance due.
••Emergency
If
we
have
not
received
a
payment
from
your
insurance
company
within
ninety
(90)
days,
you
will
be
responsible
for the balance
due. we participate.
Contact:
____________________________
Relationship:
_________________________________
Estimated deductibles, co-payments, an estimated coinsurance will be collected before services are rendered for insurances
with which
• The
Estimated
deductibles,
co-payments,
anthe
estimated
coinsurance
will be collected before services are rendered for insurances with which we participate.
insurance
company
will
determine
final
financial
distribution.
Emergency
Contactwill
Phone: _____________________
insurance
company
financial
distribution.
• The
In special
cases,
we may needdetermine
your helpthe
in final
contacting
your
insurance company for the payment of your services.
•*Our
In special
cases,
we
may
need
your help in contactinginsurances.
your insurance
for the
payment of to
your
services.
office will ONLY file to contracted/participating
It iscompany
the patient’s
responsibility
provide
our office with accurate billing information
*Our
office
will
ONLY
file
to
contracted/participating
insurances.
It
is
the
patient’s
responsibility
to
provide
with accurate
information
and to understand
the insurance benefits
and financial (CIRCLE
coverage.
the VSP
insurance□plan
requires
referral,
the our
patient
is responsible
to
assure
the
ONE) If □
MES
□aEYE
MED
□office
Principal
□billing
NVIHthat
Vision
Plan
Coverage
Information:
and to understand
the insurance
benefits
and
financial
coverage.
If the insurance plan requires a referral, the patient is responsible to assure that the
referral
has
been
received
by
the
referring
office,
before
the
exam.
Policy
Holder:
________________________________
DOB: ____/____/______ SS#:___________________
referral has
been received
by the referring office, before the exam.
Notice of Exclusion from Health Plan Benefits
Notice of Exclusion from Health Plan Benefits
Medical Insurance Information:
Self-Pay Policy
Self-Pay
Policy
The purpose of this notice is to help you make an informed choice about whether or not you want to receive these items or
The
purpose
of thisthat
notice
to help
make
informed
choice about
whether or_____________________________
not you want to receive these items or
Primary:
________________________________
Secondary:
services,
knowing
youiswill
have you
to pay
for an
them
yourself.
services,
knowing
that
you will have to pay for them yourself.
Policy
Holder:
____________________________
Policy
Holder:
___________________________
 You will be required to pay in full the same day that services are provided, at check
out.

You
will
be
required
to
pay
in
full
the
same
day
that
services
are
provided,
at
check
out.
Date
Birth:of____________________________
Date
Birth: ___________________________
 of
Methods
acceptable payments are Cash, LOCAL Bank Check
or of
Visa/MasterCard/Discover/American
Express.
 Methods of acceptable payments are Cash, LOCAL Bank Check or Visa/MasterCard/Discover/American Express.
SS#:
_________________________________
 ___________________________________
In order to provide the best medical care, we ask that you doSS#:
not discuss
your financial concerns with the physician(s) or
 In
orderstaff.
to provide
best medical
care,information
we ask that with
you do not
discuss
your financial
concerns with the physician(s) or
medical
Pleasethe
discuss
any account
check
out associate
or receptionist.
ID#: ___________________Group#:
_________ the
ID#
______________Group#:______________
medical staff. Please discuss any account information with the check out associate or receptionist.
Relationship: Self
Spouse
Parent
Relationship: Self
Spouse
Parent
Divorce/CustodyOther
Case/Personal
Representative Policy
__________
Other __________
Divorce/Custody
Representative
Policy
• The parent or guardian Case/Personal
who brings the patient
into our office will be
held financially responsible for the minor's medical expenses, regardless of the
• The parentinor
who
brings
the patient
into our office
will be heldoffinancially
the insurance
minor's medical
expenses,
regardless of the
provisions
theguardian
divorce
decree
or custody
arrangements,
and regardless
the child's responsible
relationshipfor
to the
subscriber
(if applicable).
ASSIGNMENT
OF BENEFITS
provisions
in
the
divorce
decree
or
custody
arrangements,
and
regardless
of
the
child's
relationship
to
the
insurance
subscriber
(if
applicable).
•IFor
situationsthat
where
theValley
patient
is Care
not able
to sign
legal documents,
personal
representative,
such as Power of Attorney, must provide notarized
understand
North
Eye
will bill
my medical
insurance the
carrier
for covered
services. such
• For
situations
where
thedocuments.
patient
is not
to sign
legal
documents,
the
personal
representative,
as Power
of Attorney,
must provide notarized
copies
ofValley
necessary
legal
Heable
orwith
she
must
be available
to
sign
allwill
documents,
and
must
be service,
present
during
thebeexam.
If
North
Eye
Care
is
not
contracted
my
insurance
plan,
payment
be
due
at
the
time
I will
provided with an itemized
copies of necessary legal documents. He or she must be available to sign all documents, and must of
be present and
during
the exam.
statement with which I can bill my insurance carrier.

I authorize
and request thatPolicy
insurance benefits be made directly to North Valley Eye Care on my behalf for all services furnished to me by any
Worker’s
Compensation
Worker’s
Compensation
Policy
physician
employed
by North
Valley Eye
its affiliates.
• If you are
a worker’s
compensation
patient,
it isCare
our or
policy
to bill your employer or the worker's compensation carrier for services rendered.
I am
aware that
I am responsible
for itthe
coinsurance
and any non-covered
services.
Coinsurance
are based upon
•• If
you are
a isworker’s
compensation
patient,
is deductible,
our policy
to
bill
or the worker's
compensation
carrier
fordeductibles
services
If payment
denied from
your worker's
compensation
carrier,
youyour
willemployer
become
responsible
for
the
entire
balance
ofand
your
services.rendered.
Payment
will be due
the change
determination
of my insurance
carrier/carriers.
•within
If payment
is
denied
from
your
worker's
compensation
carrier,
you
will
become
responsible
for
the
entire
balance
of
your
services.
Payment
will be due
ten (10) days following any worker's compensation payment denial.
 ten
If (10)
I do days
not have
insurance
Iworker's
understand
that payment
will bedenial.
due at the time of service.
within
following
any
compensation
payment
• It will
be
your
responsibility
to
contact
us
with
the
name
and
address
of
your
employer
or
the
insurance
company
that
covers
your
employer.

I understand
that I amtofinancially
for alland
charges
whether
not paid by
my insurance
insurance.company that covers your employer.
• It will
be
your responsibility
contact usresponsible
with the name
address
of youroremployer
or the
RELEASE OF
INFORMATION
Overdue
Balances
Overdue
Balances
authorization,
release
of be
medical
records,
•Insurance
All overdue
patient balances
will
considered
badinsurance
debt. benefits and assignments, responsibility of patient and acknowledgement
• All overdue
be considered
debt.staff (including your physician), and the independent contractor services have agreed, as
Northpatient
Valley balances
Eye Care,will
employees
of its bad
Medical
permitted by law, to share your health information among themselves for the purposes of treatment, payment or health care operations. This
To helpenables
in this us
policy
we ask
thatyour
youhealth
assistcare
us at
the time
service by:
to better
address
needs.
This of
information
is being provided to you as a supplement to The Notice of Privacy
To
help in this
policy
we ask
that
you assist
us at
the
of
service
by:
1. Providing
us with
and
updated
ontime
yourself
andofyour
insurance
company.
Practices
givencurrent
to you by
North
Valleyinformation
Eye Care. For
the
purposes
treatment,
payment,
or health care operations, I authorize the release
1.
Providing
us
with
current
and
updated
information
on
yourself
and
your
insurance
company.
of all medical
records
and any
insurance information
between North
Care, its
affiliates,
2. Presenting
an updated
photo
identification
card and insurance
cardValley
whenEye
changes
are
made. my family physician, insurance carriers and
2.
an
updated
photo
identification
and claims
insurance
card
changes are
made.
the the
Health
Care Financing
Administration
tocard
process
for related
services.
3. Presenting
Making
appropriate
payment
at the time
of service;
whether
it iswhen
a deductible,
copay,
coinsurance, refraction, or for the full amount
3.
Making
the
appropriate
payment
at
the
time
of
service;
whether
it
is
a
deductible,
copay,
coinsurance, refraction, or for the full amount
 are
I hereby
authorize
said assignee to release information necessary to secure payment.
if you
a Self-Pay
Patient.
if you
a Self-Pay
Patient. and electronic submission of such information.
 are
I allow
for fax transmission

A scan and/or photocopy of this assignment will be considered as valid as an original.
By signing below I have read and understood the financial policies of Royo Eye Care and also I understand that Royo Eye Care reserves the right to change any and
I have
read Iand
understood
the financial
policies of
Ridge
Eye Care
and also
I understand
that Ridge
Eye Care
reserves
thebehalf
right to
any and
Byfees
signing
below
all
at any time
without
notice.
authorize
and request
that insurance
and
all other
pertinent
benefits
be made directly
to Royo
Eye Care
on my
forchange
all services
CONSENT
FOR
TREATMENT
all
fees at to
any
without
notice.employed
I authorize
thator
insurance
and all
other pertinent
benefits
be medical
made directly
to Ridge
Eyeme
Care
on my behalf
for all services
furnished
metime
by any
physician
by and
Royorequest
Eye Care
its affiliates.
I authorize
the release
of any
information
about
necessary
to determine
benefits
furnished
me byand
any physician
employed by the
Ridgeabove
Eye Care
or its affiliates.
I authorize the
release
of any medical
information
about me necessary
to determine
benefits
I have
fully understand
consent
for evaluation
and
treatment,
financial
responsibility,
release
of medical
for
relatedtoread
services.
for
related services.
information
and insurance authorization.
______________________________________________
Signature of Patient / Parent / Guardian / Conservator
___________
Date
__________________________
Reason patient is unable to sign