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Cox Family Eye Care, P.C.
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CFEC Financial Consent

  • Prior to care being rendered by Cox family Eye Care, P.C., please read and complete this form. To be eligible for insurance benefits, it is the responsibility of the patient to be aware of insurance coverage, to make our office aware of insurance coverage and to present applicable insurance cards prior to services being rendered or materials being ordered.
  • For Medicare patients - Eye care services covered by Medicare include examination and treatment services related to symptoms and signs of ocular disease. Medicare will only pay for services that it determines to be “reasonable and necessary” under section 1862 (a) (1) of the Medicare Law. Medicare does not pay for the refraction (determination of spectacle or contact lens powers).
  • For Hoosier Healthwise (Medicaid) patients- Within the guidelines of the patient’s eligibility, Medicaid provides for comprehensive eye examination and refraction and basic eyeglass frames and lenses. Medicaid does not cover screening retinal imaging, deluxe frames, scratch or ultraviolet or antireflective lens coatings, tint colors other than pink, lens materials other than basic plastic or polycarbonate, progressive or specialty “bifocal” lenses, contact lens services or contact lens materials. Charges for non-covered materials or services will be the responsibility of the Hoosier Healthwise beneficiary.

    Patient medical records are confidential. I understand that by signing this consent form I acknowledge that I have received and had an opportunity to review and understand Cox Family Eye Care, P.C. “Notice of Privacy Practices” and that I am allowing my medical information to be released upon the request of agents for the Social Security Administration, Health Care Financing Administration, Medicare, the Hoosier Healthwise Program (Medicaid) or my contracted insurance carrier, to agents for the aforementioned party, for the purpose of Health Care Operations (including, but not limited to, provider review functions, claims payment and quality assessment). I also understand that I may revoke this consent by written request, at any time, with Dr. Cox. If revoked, it is understood by all parties that all information released prior to being notified of such revocation was made with my consent. I understand that I have the right to restrict the disclosure of specific information in my medical records if I request such restriction in writing. I understand that my request for restriction may be denied if the PHI restricted is required for Health Care Operations.


    I, being the above named patient or parent or legal guardian of above named patient, do hereby give consent for Cox Family Eye Care P.C. or its representatives to submit (on my behalf) applicable charges for services and / or materials to Social Security Administration, Health Care Financing Administration, agent of Medicare, agent for the Hoosier Healthwise Program (Medicaid) or any applicable insurance carrier. I further authorize all insurance companies or agents of Medicare or agents of Medicaid to release to Cox Family Eye Care, P.C. or its representatives any information needed to resubmit denied or incorrectly paid claims.


    I grant permission for personnel of Cox Family Eye Care, P.C. to contact me via telephone (voice or text messaging), e-mail and/or mail service at my home or place of employment, for the purpose of Health Care Operations (including but not limited to appointment reminders, conveying the results of medical tests, arranging for materials dispensing, collection of unpaid patient account balances).


    I authorize Dr. Cox and / or the staff of Cox Family Eye Care, P.C. to examine me, or my dependent, and undertake necessary treatment steps on behalf of me, or my dependent, as would be acceptable under the “standard of care”. I understand that a base eye examination includes a comprehensive health examination of the visual system, determination of refractive error and digital imaging of the retina.


    I accept financial responsibility for charges incurred as a result of care rendered or materials supplied by Dr. Cox and / or the staff of Cox Family Eye Care, P.C that my applicable insurance may be expected to deny payment, has denied payment, or has failed to respond to within 30 days of claim submission. I understand that a Collection Service and / or Attorney may be utilized to collect unpaid patient account balances that are aged greater than 90 days. I understand that a collection fee equal to 33% of unpaid balance will be added to past due patient balances forwarded to a Collection Agency and/or an Attorney.

    I have read the above and foregoing consent for release of information and financial responsibility statement. I do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this form
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