Patient Authorization Form

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E
C
A
YE
LINIC OF
USTIN
One Far West Building  3410 Far West Blvd  Suite 140  Austin, Texas 78731
(tel) 512.427.1100  (fax) 512.427.1207
Thomas Henderson MD
Melanie Prosise MD
____________________________________________________________________________________________________________________________________
Patient Authorization Form
(Initial)________FINANCIAL RESPONSIBILITY:
1.
I understand that I am ultimately responsible for payment on my account & Payment is expected at the time of service.
2.
I understand that I am responsible for any referral or authorization that my insurance may require and for any charges that are
NOT covered by my insurance plan, including refractions, co-payments, co-insurance and deductibles.
3.
ECOA will file claims for companies we are contracted with, including Medicare, Medicaid, and Tricare. Payment of benefits
will be made directly to Eye Clinic of Austin.
4.
I understand and accept that if I make a payment with a check and that check is dishonored or returned for any reason ECOA
will bill me for the amount of the check plus a processing fee of $25.00.
5.
I understand that if I do not pay all of the charges due from me and my past due account is sent to an outside collection
agency, an additional fee equal to the collection agency’s commission will be added to my outstanding balance.
(Initial)________INSURANCE COVERAGE:
I understand that I am responsible for providing my physician with any and all
insurance coverages at each and every visit. I will be responsible for any balances due as a result of not disclosing this information.
(______Staff Initials)
(Initial)________LABORATORY FEES:
I understand that my physician uses Clinical Pathology Laboratory (CPL). ECOA
cannot guarantee my insurance will cover any lab/pathology preformed at or ordered by my physician. If my insurance requires use of
a different lab, I understand it is my responsibility to inform my physician for proper handling.
(Initial)________I DO CONSENT
to necessary examinations and/or treatments performed and prescribed by my physician as is
necessary in his/her judgement, with patient approval. Separate consent forms will be signed for procedures performed in the
physician office.
(Initial)________PRESCRIPTIONS:
I understand that ECOA uses electronic prescribing. My prescriptions will be sent and my
medication information may be obtained through ECOA’s electronic prescribing function.
(Initial)________RELEASE OF INFORMATION:
I do hereby authorize my physician to disclose information to the
pharmacy, lab, and hospital facility in the event of a scheduled surgery, procedure, or emergency care. I authorize the disclosure of
any medical records or other information necessary to process my insurance claim.
(Initial)________RELEASE OF PHI:
I do hereby authorize ECOA to disclose information to the following recipients(s)
regarding my Protected Health Information.
Recipient Name: ____________________________________________ Recipient Phone: __________________________________
Relationship to Recipient _____________________________________ Recipient Email: ___________________________________
Purpose (s) for the disclosure (ie. All, Labs, Pharmacy, Billing) ________________________________________________________
I acknowledge that I have received or have access to a copy of ECOA’s Notice of Privacy Practices.
(Initial)________HIPAA:
(Initial)________FEE FOR FORMS COMPLETION:
I understand that I will be responsible for paying $15 for forms
completion by my physician or staff. (Examples: Disability forms, FMLA, ect.)
I would like to receive ________(Initial) Email or _________ (Initial) text to my mobile device regarding appointments.
Spouse/Partner’s Name: ____________________________________ Spouse/Partner’s Work Phone: __________________________
Spouse/Partner’s Employer: _________________________________ Spouse/Partner’s Occupation: ___________________________
Emergency Contact: _______________________________________ Emergency Phone: ___________________________________
(other than spouse)
Your Signature: __________________________________________ Today’s Date: _____________________________________

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