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Person Responsible for Account

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Insurance Company Information

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Group Number

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Phone Number

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Insured's Name

First Middle Last

Relation

Insured's Id Number

Insured's Social Security Number

Insured's Birthday

***If there are secondary insurance benefits, please let us know.***

Patient/Doctor Agreement

I hereby agree to pay all charges if the insurance company does not pay in full within 60 days. I will pay the balance in full or make arrangements to pay on a monthly or weekly basis.

Signature of Responsible Party:

Today's Date

Acknowledgment of Privacy Policy and Practices

I understand that in an attempt to protect the privacy of my identifiable health information, Drs. Akel and Favale, P.L. has established a Privacy Policy and guidelines of Privacy Practices within this office. This information details the use and/or disclosure of information contained in my personal medical/optometric records kept for the purpose of diagnosis, treatment, payment and health care operations. In accordance with HIPPA Regulations, a copy of the Privacy Policy & Practices has been made available to me while in the office today. Should I choose to have a personal copy, one will be given to me at no charge.

I have read, I understand, and I acknowledge the Privacy Policy & Practices of Drs. Akel and Favale, P.L.
I have elected not to read the Privacy Policy & Practices of Drs. Akel and Favale, P.L.
A copy of the Drs. Akel and Favale, P.L. Privacy Policy & Practices

Patient Consent for Use and Disclosure of Protected Health Information

Thereby give my consent for Drs. Akel and Favale, P.L. to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO).

Drs. Akel and Favale, P.L.'s Notice of Privacy Practices provides a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Drs. Akel and Favale, P.L.'s reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice may be obtained by forwarding a written request to Drs. Akel and Favale, P.L. Privacy Officer, Anthony Favale at 953 Lane Avenue South, Jacksonville, Florida 32205.

By signing this form, I am consenting to Drs. Akel and Favale, P.L.'s use and disclosure of my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later decline it, Drs. Akel and Favale, P.L., may decline to provide treatment to me.

Patient's Name

Signature of Patient or Legal Guardian

Date

REGARDING VISIONCARE & MEDICAL INSURANCE

We often have patients that have both vision insurance (for example, VSP or EyeMed) and medical insurance (for example, Blue Cross, Aetna, Blue Shield, or Medicare). They are very different in terms of the services they cover, and it's important for our patients to understand these differences.

Vision insurance is designed mainly to cover determining a prescription for glasses, to help pay for glasses or contact lenses, and to cover a yearly routine evaluation of the health of the eyes in a healthy patient that has no particular problems or symptoms. It is not equipped to deal with and does not usually cover medical conditions, injuries, and/or treatments, Medical insurance is designed to cover you when you have a medical problem, including one that affects your eyes. Medical insurance does not cover routine services or examinations for glasses, or routine vision problems such as nearsightedness, farsightedness, and astigmatism. Those are only covered by your vision insurance.

When a medical diagnosis or medical condition is present that affects your eyes, such as high blood pressure, high cholesterol, or diabetes, to name just a few examples, or you have an eye disease or eye problem such as an infection (pink eye), dry eyes, allergy, or cataracts, again, just to name a few, we must file the claim with your medical insurance, and the co-pays and deductibles for that insurance will apply. Your vision plan does not cover these kinds of problems. Our office does not make these rules, they are made by the insurance companies themselves, and we must comply with them.

There is often no way to know prior to your examination which type of insurance will be the right one to file your claim with. We make every effort to join as many insurance panels, both medical and vision, as we can for your convenience. If we are on your insurance company's panel we will file those claims for you. In the event that we do not accept your medical or vision insurance we will provide you with an itemized receipt so that you may file a claim for reimbursement with your insurance company yourself. If you have any questions, please let us know.

understand the information I've just read about the difference between vision and medical insurance. I authorize Drs. Akel and Favale, P.L. to file my claim with the appropriate insurance based on the reason for my visit and the results of my examination.

Date

Medical Information Release Form (HIPAA Release Form)

Name

First Last

Date of Birth

Release of Information

l authorize the release of information including the diagnosis, records; examination rendered to me, and claims information. This information may be released to

Spouse
Child(ren)

Information is not to be released to anyone.

This Release of Information will remain in effect until terminated by me in writing

Messages

Please call

my home
my work
my cell

Number

If unable to reach me

you may leave a detailed message
please leave a message asking me to return your call

The best time to reach me is (day).

between (time).

Signature

Date

Witness

Date

Patient Info Sheet