Medicare Signature on File

I request that payment of authorized Medicare benefits be made on my behalf to Dr. Robert Janot – Vision Source, for services furnished to me. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services (CMS) and its agents any information needed to determine these benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in item 9 of the CMS 1500 form or elsewhere on other approved claim forms, my signature authorizes releasing the information to the insurer or agency shown. Dr. Janot accepts Medicare assignment, that is, the charge determination of the Medicare carrier as the full charge, BUT,

I UNDERSTAND THAT MEDICARE DOES NOT PAY FOR THE FOLLOWING AND THAT I AM RESPONSIBLE FOR PAYING THESE ITEMS ON THE DAY OF MY APPOINTMENT:

• My annual deductible (must be paid each calendar year) If your deductible is not met, we will collect Medicare allowed charges today, and Medicare will apply that amount to your deductible for this calendar year.
• My co-insurance (20% of the Medicare allowed charge)
• Non-covered services (ex: routine exams to change or replace glasses / refractions to determine glasses prescription / routine Optomap retinal scans).

**PLEASE NOTE: WE WILL COLLECT THE ABOVE ITEMS (WHERE APPLICABLE) AT THE TIME OF SERVICE.

I agree that in return for the services provided to me by Dr. Janot, I will pay my account at the time service is rendered. I also agree to pay any amounts I may owe above and beyond what was paid at the time of service, within 30 days of receiving a bill. If an account is sent to an attorney for collection, I agree to pay collection expenses and reasonable attorney’s fees. I understand and agree that if my account is delinquent, I may be charged interest.

*NOTE* During this time of the COVID-19 Pandemic, submitting this form electronically will replace the staff signatures typically required. Patients should still type their name in the boxes here, sign the form where requested, and submit electronically.

If the patient is unable to sign, his/her mark is also acceptable, so long as it is co-signed by the caregiver. If the patient is unable to even mark the box, a caregiver may sign in place of the patient.