Tucker & Associates Eye Care and LaserCenter

In order to accommodate the needs and requests of our patients, we have tried to enroll in a number of managed care insurance programs. While we are pleased to be able to provide this service to you, it is impossible for us to keep track of all the individual requirements of these plans. Each plan has different stipulations regarding its policies.

It is your responsibility to contact your insurance company and find out whether our doctors are participating within your particular insurance plan. Some insurance carriers have a PPO, POS, HMO or indemnity status, along with their new Medicare HMO Plans, and it is very possible that our doctors may participate in one of these areas, but not participate in all.

It is your responsibility as the patient to give us the proper insurance card(s) at time of visit. It is also your responsibility to get the proper referral and authorizations from your insurance company or PCP (if applicable) prior to your office visit if your medical or vision insurance company requires one. These authorizations/referrals can be faxed to us at 770-813-0029, or you can bring them in on day of your visit. If you fail to do so, you (the patient) will be responsible for payment if your insurance company denies the claim for services done without prior authorization/referral. This applies to all vision plans and medical insurance companies especially HMO plans.

CompBenefits patients: You (the patient) will need to call CompBenefits to get your VisionPASS Authorization BEFORE YOU COME FOR YOUR APPOINTMENT.

Please note that our office will obtain authorizations for Davis Vision, VSP, EyeMed (Cole), Avesis, OptumHealth (Spectera), Superior Vision and Clairty Vision Plans.

It is your responsibility to read and understand your own insurance policy. Certain services and procedures may or may not be covered, depending on your individual insurance policy.

In the event that:

1)Insurance coverage is not paid as in-network because we are not participating physicians in your plan;

2)Insurance coverage is not in effect on the date of your visit; and/or

3)A non-covered service is performed or denied for the reason “not medically necessary”

We will have no choice but to bill you directly for all charges related to your visit(s).

I have read and understand the policy and agree to accept the responsibility described.

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INFORMATION AND INSURANCE AUTHORIZATION

I UNDERSTAND THAT TUCKER ASSOCIATES EYE CARE AND LASER CENTER HAS AGREED TO FILE MY INSURANCE, OR TUCKER ASSOCIATES EYE CARE AND LASER CENTER IS A PARTICIPATING MEMBER OF MY INSURANCE PLAN, I HEREBY AUTHORIZE TUCKER ASSOCIATES EYE CARE AND LASER CENTER TO FILE MY INSURANCE DURING THE TERM OF MY TREATMENT, USING THE TERM "SIGNATURE ON FILE" AS MY SIGNATURE.

I AUTHORIZE DIRECT PAYMENT TO TUCKER ASSOCIATES EYE CARE AND LASERCENTER BY THE INSURANCE COMPANY FOR ALL SERVICES RENDERED TO ME DURING THE TERM OF MY TREATMENT.

I UNDERSTAND THAT ALTHOUGH TUCKER ASSOCIATES EYE CARE AND LASERCENTER HAS AGREED TO FILE MY INSURANCE, THAT I AM ULTIMATELY RESPONSIBLE FOR ANY UNPAID BALANCE OF MY ACCOUNT.

I AUTHORIZE TUCKER ASSOCIATES EYE CARE AND LASERCENTER TO RELEASE TO THE INSURANCE COMPANY OR TO A PHYSICIAN ANY INFORMATION REGARDING MY TREATMENT.

Signed:______Date:______

Revised 12/10