Patient History Form

AUTHORIZATION OF TREATMENT: I authorize my physicians Dr. Kingrey, Dr. Boomer, Dr. John, and/or Dr. Klenda to examine, diagnose and treat any eye related illness I may have.
AUTHORIZATION TO RELEASE INFORMATION: I authorize Dr. Kingrey, Dr. Boomer, Dr. John, and/or Dr. Klenda to disclose information regarding my illness to my Physician, Optometrist, Medical Facility, or my Insurance Company. A photostat copy of this authorization will be considered valid.
CONTACT RELEASE INFORMATION: I authorize/permit Vision Surgery Consultants ie: Dr. Kingrey, Dr. Boomer, Dr. John, and/or Dr. Klenda and their business associates to contact me, and all other responsible parties on my account, on our cell phone or other mobile devices concerning any and all aspects of my account.
ASSIGNMENT OF BENEFITS: I assign and authorize for direct payment of medical benefits otherwise payable to me by my insurance to: Vision Surgery Consultants, P.A. I understand that I am financially responsible for charges not covered by my insurance. If incorrect or wrong insurance is supplied to this office, or if I have AN HMO INSURANCE AND DO NOT HAVE PRIOR APPROVAL IN WRITING BY MY PRIMARY CARE PHYSICIAN TO BE SEEN, then I agree to pay for all charges if examined.
CANCELLATION POLICY: If you do not cancel or reschedule your appointment within 24 hours notice, we may assess a $75.00 No-Show service charge. This charge is not reimbursable by your insurance company. You will be billed directly. After three no-shows to your appointment, our practice may decide to terminate its relationship with you.