APPOINTMENT CHECKLIST-PEDIATRIC

Para español, seleccione del menú desplegable en la esquina superior derecha.

• Current health insurance information, including ID card
• Photo identification
• Completed registration forms. They may be filled in online but must be printed.
  The check-in time is when the patient presents completed registration forms, not when the patient arrives. Please arrive 20-30 minutes prior to your appointment time if forms need to be completed in the office.
• Referral/Authorization (if required by your insurance)
• List of all medications your child takes (including strengths/dosages)
• Pharmacy information (name, address, and phone number)
• Please bring a translator, if necessary.
• Copays and other out of pocket expenses will be collected at check-in. We accept cash, check, and most credit cards.
• Glasses and/or contact lenses (Please bring contact lens boxes with lens information.)
• If relevant, please bring records pertaining to your child’s condition such as relevant MRI/CT results, labwork, operative reports, etc.
• We require a parent or guardian accompany the child to the initial visit.
• We ask that you not bring siblings or other family members that are not being seen to the appointment as they may distract your child during the examination.
• Toys/activities for your child to play with as some appointments can take 2-3 hours.
• Please allow sufficient travel time. If you arrive more than 20 minutes after your scheduled appointment time, you may be asked to reschedule.

Ideal EyeCare ● 6028 S. Fort Apache Road, Suite 101 ● Las Vegas, NV 89148

Ideal EyeCare Registration Form-Pediatric

Financial Responsibility for Dependent Patients: Parent/Guardian Information

Insurance Information

Patient’s or Authorized Person’s Signature
I understand that even if Ideal EyeCare is contracted with my insurance plan, I am ultimately responsible for payment of both covered and non-covered services performed during the course of my treatment. I understand that any payment collected today is an estimate of my total liability and additional monies may still be owed once my insurance plan has processed the claim. I request payment of
authorized benefits by my insurance plan be made to Ideal EyeCare for services rendered and request that Ideal EyeCare submit claims for payment for those services on my behalf to my insurance carrier. I authorize the release of any/all medical information to the insurance carrier or its agents to allow for benefit or claim determination. I understand that if Ideal EyeCare does not participate
with my insurance plan or if I have elected to receive care outside of my insurance coverage, I am assuming financial responsibility for all services rendered and no claim will be filed to my insurance company on my behalf. I certify that the information provided above is complete and accurate and assume any and all financial liability caused by omissions or inaccuracies.

We also offer a multitude of aesthetic services!

Medical History Questionanaire-Pediatric

Social History 

Birth History

Review of Systems

I have completed this form as accurately as possible. I understand that providing incorrect information or omitting information can be dangerous to my child's health and it is my responsibility to inform the office of any changes in his/her/their health status.

FINANCIAL POLICY

The following information is regarding your account at Ideal EyeCare. Please read these policies carefully and discuss any questions or concerns with our staff. We  look forward to providing you and your family with excellent eye care.

• Payment is due at the time services are rendered. This may include co-pays, deductibles, co-insurance, non-covered services, etc. We accept all major credit cards as well as debit cards, cash, and checks.
• It is your responsibility to know your insurance coverage and to provide our office with the most current and accurate information. While our staff is extremely knowledgeable about many insurance plans, coverages change  frequently and we cannot be held liable for misquoted benefits or eligibility.
• If your insurance requires a referral, you are responsible for contacting your  primary care physician/pediatrician to obtain said referral. It is also your responsibility to verify that a valid referral is on file for all visits.
• The determination of your best corrected vision is called a refraction. This is considered a non-covered service/procedure by most insurance companies. You will be responsible for the $55.00 fee when this service is
  performed. Strabismus patients are responsible for an additional fee of $40.00 for a prism refraction (total $95.00). We will bill this service to your insurance as a courtesy, and if they pay any portion, you will be refunded their payment amount.
• For those patients being followed for strabismus, a sensorimotor examination will be performed at each visit. This service is separate from the office visit and may be considered a diagnostic test by your insurance, resulting in
  additional out-of- pocket cost to you.
• Telemedicine visits, whether scheduled or requested, will be billed to your insurance company and you may be responsible for out-of-pocket costs such as copays or deductibles.
• We do not participate with any vision plans and you are responsible for all “routine” and/or non-covered services provided to you or your child. This includes myopia management evaluations.
• All “self pay” patients are required to pay in full at the time services are rendered. We offer a 20% prompt-pay discount on all professional services and will provide you with an itemized receipt.
• Our office does not accept insurance liens, workers compensation, or  attorney liens. Payment is the patient’s responsibility and is due in full at the time of service.
• The parent bringing the child for treatment is responsible for payment, regardless of the terms of any divorce decree or custody arrangement.
• All outstanding balances must be paid in full before scheduling surgery, except in emergent cases.
• All delinquent accounts may be sent to a collection agency and you may be  charged any/all applicable collection and attorney fees. Once an account has been transferred to collections, you and your immediate family members will be discharged from the practice.
• All returned checks are subject to a $35.00 processing fee and will result in refusal to accept future payments by check.
• Any account credit balance less than $2.00 will not be issued a refund check.
• We charge a $25.00 per page fee for any and all forms that require the  doctor’s signature and review. This service will not be billed to your  insurance company. Payment is due before the form(s) will be released. A  receipt will be provided at the time of payment.
• There is a $50.00 per page fee for summary of care letters or other requests  requiring a drafted and signed letter from the doctor. 
• You will be assessed a $50.00 NO SHOW fee for any appointment that is  missed or cancelled within 24 hours of your scheduled appointment. You  must pay this amount before you will be allowed to schedule another  appointment. We offer reminder notifications be text/phone/email as a  courtesy, but it is your responsibility to update your calendar. It is very  important that you keep our office updated with your most current  information.
• Per NRS 629.021, we charge $0.60 per page for copies of your medical  record, whether provided via paper or electronic access. You may also be  assessed applicable postage costs if you prefer to have the records sent via  mail. These fees are waived if records are transferred directly to another  physician for continued care.

I have read and understand the above information.