Patient Forms
New and Existing Patients
Save time during your visit! Download and complete our patient forms at home and then bring them with you to your appointment.
- Full Patient Packet (18 pages)
Individual Forms
If you need an individual form, please choose one from the list below.
- Packet Acknowledgement
- Brochure
- AAAHC Letter
- Spectra Eye Notice of Privacy Practices
- Advance Directive
- Patient Rights and Responsibilities
- Grievance Procedure
- Direct Interest Notice
- Health and History
- TB Assessment
- Advance Directives for Health Care Decisions
- Anesthesia Billing Information
Insurance Information
We will be happy to assist you in filing the insurance claim for your surgery. In order to do this, we will need copies of your insurance cards.
Medicare Patients
We are an approved Medicare facility. Therefore, we will bill Medicare according to their allowable rates. As a Medicare Part B participant, you are only responsible for the annual deductible, the 20% of the charges, known as "co-insurance", and any non-covered services. A Medicare supplement insurance policy may cover these charges.
Contracted Insurances
We are contracted with many major insurance plans. If you are covered under any of the plans, we will bill your insurance under the contracted guidelines. If your coverage indicates a copay, deductible or any portion for you to pay, you will be expected to pay that amount on the day of service.
Private Insurance Patients
If w have a contract with your insurance carrier, we will file the claim for you. Since we have no control over your policy limits, filing of your insurance claim does not relieve you of responsibility for the full charges.
Self-Pay Patients
If you do not have health insurance coverage, or if your insurance company will not cover your services at Spectra Eye Institute, payment for your surgery will be expected at the time of admission, unless prior arrangements have been made with our facility.
We accept many forms of payment: cash, check, money order, debit card, VISA, Mastercard and Discover. Please come prepared to pay your deductible, co-pay and/or co-insurance at the time of surgery.