Information & Registration

*your e-mail address will be held in a secured database and will not be sold or shared with any other company or organization

Person Responsible for Financial Statement(Complete if patient is under 18 or a student)


May we speak with anyone other than yourself regarding financial statements, test results, or any other services provided by our office regarding your medical treatment?

Please help us thank your friend or family member for introducing us to you. Were we recommended by a friend of family member? If so, Who?:

Were you sent to us by a doctor who we need to update on your vision care?

Please give us the name of your Family physician as well.

Insurance Information

If yes, please provide employer, phone number & contact person:

There is a discretionary fee of $50 that may be assessed to the patient′s account when the patient is "No Show" on their appointment date or when an appointment is not cancelled or rescheduled at least 24 hours in advance.

Please read carefully, a copy of this form will be provided to you for signature in-person on the day of your appointment

Insurance Release Form

Authorization for Treatment

While I am at the Kansas City Eye Clinic(hereinafter, The Eye Clinic*), I permit the employees, the healthcare provider and all other persons caring for me to treat me in ways they judge are beneficial to me. I understand the attending healthcare provider will explain to me the nature of my condition and his/her recommended treatment and any associated risk involved with that treatment. I also understand that they will explain to me the other ways my condition could be treated. I further understand that this care may include diagnostic testing, examinations, medical and/or surgical treatment and no guarantees have been made to me regarding the outcome of this care.

Medicare Lifetime Consent

I certify that the information given by me in applying under the Title XVII of the Social Security Act is true and correct. I authorize any holder of my medical or other information to release this information to the Social Security Administration, its intermediaries or carriers as required to support a Medicare Claim for services provided by The Eye Clinic. I authorize The Eye Clinic to submit a claim for Medicare benefits payable on my behalf. I request that payment of authorized Medicare benefits be made directly to The Eye Clinic and/or its doctors on my behalf; I assign those benefits to The Eye Clinic and/or its doctors.

All Other Insurance

Authorization is hereby granted to The Eye Clinic to release medical records and other requested information for the completion of claims to my insurance company. I further authorize payment for medical benefits to be made directly to The Eye Clinic. I understand that I am personally and financially responsible for all services provided by The Eye Clinic, unless covered by Worker′s Compensation.

(*"The Eye Clinic" refers to the Kansas City Eye Clinic, its doctors and employees where appropriate)

Please read carefully, a copy of this form will be provided to you for signature in-person on the day of your appointment

Clinic Financial Policy

This information has been prepared for you benefit and reference. It contains our policies regarding insurance plans, billing and payment for our services.

Please read and initial each statement in the blank provided

The Kansas City Eye clinic will file claims for primary and secondary insurance plans on your behalf. Co-payments, charges for non-covered services and deductibles are due in full at time of service.

It is your responsibility(and the guardian of minors′ responsibility)to be aware of and follow your insurance plan guidelines and restrictions.You are responsible for obtaining a referral if your plan requires one. You are responsible for selecting a provider that participates with your insurance. The most up-to-date and comprehensive list of participating providers is available when you speak directly with your insurance plan; the Kansas City Eye Clinic cannot provide as up-to-date a list. You must use the information provided by your insurance company to determine if your doctor is a participating provider.

The Kansas City Eye Clinic does NOT file claims to automobile or liability insurance. Payment for all charges is due at the time of service. The patient will be provided with the information they need to file their own claim to the insurance company.

Kansas City Eye Clinic will follow-up on unpaid insurance claims. However, your insurance coverage is an agreement between you and your insurance plan and it is your responsibility to assure that services are paid. If your insurance coverage changes, delays or denials as a result of insurance information that is incomplete or not up-to-date will result in the payment for services and materials due directly from the patient.

Adult or teenage children who require examination, treatment, eyeglasses or lenses must have required insurance information and be prepared to pay any balance or fee not covered by insurance.

Routine vision plans will not cover exams when the patient has a vision or eye complaint or a medical diagnosis. These plans are generally for healthy eye exams and cannot be billed for care when there is a complaint or a medical diagnosis.

Most insurance companies consider a refraction to be a non-covered service. A refraction is the test used to determine the power and prescription of your eyeglass or contact lenses. You are responsible for payment of the refraction if your insurance does not cover it.

Your Social Security number is a required part of your financial information with the Kansas City Eye Clinic. This information, as with your medical record, is protected with strict confidentiality. When the Clinic does not receive full payment for all charges at the time of service, by definition, we extend credit to the patient, and consequently can appropriately ask for this information to be part of our records. Alternatively, all charges can be paid in full until insurance makes payment after which we will process a refund to the patient.

The Kansas City Eye Clinic will assess a charge for copies of medical records to cover the costs of processing the record. A patient will be provided 10 pages of their medical record at no charge. Additional or subsequent pages will be provided at 50 cents per page and a $10.oo processing fee per occurrence after appropriate authorizations have been made.

Please read carefully, a copy of this form will be provided to you for signature in-person on the day of your appointment


Allergies: Reaction Severity

Past Ocular History: (Please mark all that apply)

Ocular Surgeries: (Please mark all that apply)

Current Medications used on or for YOUR EYES : (Please list)

Ocular Significant Illnesses: (Please mark all that apply)

Systemic Illnesses:

Infections: (Please mark all that apply)

General Surgeries / Operations: (Please list)

Any Medications (OTHER than the Eye Medications you have already listed)check

Family History:

Review of Systems: Are your CURRENTLY EXPERIENCING any of the following (Please mark all that apply)


Ear, Nose, and Throat








Blood / Lymph nodes