Dr. Kiefer and Associates

INSURANCE INFORMATION
Do you have insurance to use for this exam?

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If yes, pleases fill out the sections below.
Vision Insurance is for routine eye exams, and purchasing glasses or contact lenses.
Vision Carrier
Policy ID Number
Name of Policy Holder

First Name Last Name
Holder's Date of Birth

Month Day Year
Date
Medical Insurance is for diabetic eye exams, cataracts checks, eye injuries, eye infections, etc.
Medical Carrier
Policy ID Number
Name of Policy Holder

First Name Last Name
Holder's Date of Birth

Month Day Year
Date
Our office submits necessary billing and medical information to insurance companies as a courtesy. We may not be able to do this for all insurances, especially for out-of-network insurances. Copays and fees are due at time of service. Coverage is determined by your insurance company and verification of your policy is not a guarantee of coverage. Any services applied towards deductibles or deemed non-covered services are your responsibility.
Please check this to acknowledge the information above regarding insurance coverage and your financial responsibility
Exam Services Information

Routine Exam: Our routine exams are $114 without insurance. If you have in-network vision insurance, your costs will likely be your insurance copay plus $24 for retinal images (i.e., $10 copay + $24 = $34 for the exam). Retinal images are a required service and are usually not covered by insurance. Contact Lens Fit: A contact lens fitting and evaluation is completed in addition to a routine exam, if you would like a prescription for contact lenses. This service ranges $50 - $120 without insurance, depending on the lens type and complexity of your prescription. These fees may still apply to you, even if you have insurance. Office Visits: Office visits for medical concerns or emergencies range from $50 - $200, depending on the severity and complexity of the issue. We bill medical insurances when possible, but you may be responsible for a copay today or for the full amount if services are applied to a deductible or denied.

HIPAA Acknowledgment
The Health Insurance Portability and Accountability Act (HIPAA) is a set of rules to be followed by all healthcare providers. HIPAA helps ensure that all medical records, medical billing, and patient accounts meet certain consistent standards, with regard to documentation, handling, and privacy. Please sign below to acknowledge that you've been provided an electronic or hard copy of the privacy policy from Dr. Douglas C. Kiefer & Associates, PC.
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PATIENT INTAKE FORM

INSURANCE INFORMATION

Vision Insurance is for routine eye exams, and purchasing glasses or contact lenses.

Medical Insurance is for diabetic eye exams, cataracts checks, eye injuries, eye infections, etc.

Ocular and Health History

Do you or any immediate family members have any of the following eye conditions?

Do you or any immediate family members have any of the following medical conditions?

Have you had any of the following procedures?

HIPAA Acknowledgment