Insurance Form We accept payment from a variety of insurances both medical plans, and discounted vision plans. Most patients find this page because they're trying to find out which plans we accept and which ones we don't so they might be able to predict their out of pocket costs in our office. In order to best answer your question, we need some information first. If you cannot answer these questions, please contact your insurance or employer's HR dept to get the answers.1. Do you have any insurance through an employer or government agency? Yes No Is it: A commercial plan through an: Employer Federal (Medicare) Federal (Tricare) State (Medicaid) Have you purchased coverage independently through an exchange? Select one from the list below: Aetna Cigna BCBS/Anthem Humana United Health Care Kaiser Permanente PHCS/Multiplan Other Other We are in-network providers for most plans with this insurance. However, there are some commonly performed procedures routinely done in our office that this insurance will NOT cover. These procedures are seen as imperative to our doctors’ standard of care and are sometimes required for the most accurate diagnosis of your condition. We are in-network providers for most plans with this insurance. However, there are some exceptions. Does your insurance card have ANY of the following on it? Health Spring HMO No. My card does not indicate any of these plans We are in-network providers for most plans with this insurance. However, there are some exceptions. Does your insurance card have ANY of the following on it? EPO (Exclusive Provider Organization) HMO (Health Maintenance Organization) Pathway X No. My card does not indicate any of these plans We are in-network providers for most plans with this insurance. However, there are some exceptions. Does your insurance card have ANY of the following on it? Core Charter HMO No. My card does not indicate any of these plans We are not providers for this insurance. We cannot bill them on your behalf. You must see a Kaiser Provider to utilize your insurance. If you would like to understand how much you can expect to pay in our office, please go to the Price Predictor tool and indicate “Cash Pay.” 2. Have you elected to carry a vision plan in addition to your medical plan? Yes No You have indicated that you carry both a commercial medical plan, and an additional vision plan. The determination for which plan will be billed for your services will be made based on the reason for your visit.HiddenPlease indicate if you are seeking care for: A wellness exam: Nothing is wrong, but you'd like to get a prescription for glasses or contacts and make sure there's nothing to worry about. A sick exam: You are in pain, or an eye infection. You might have a specific ocular condition that you'd like the doctor to manage or another doctor has referred you to us for an eye exam. What is the name of your vision discount plan? If you are unsure, please contact your employer’s HR dept to find out. Do NOT call your health insurance plan. Avesis Davis Vision EyeMed Guardian NVA (National Vision Administrators) Spectera (United Health Care Vision) Superior Vision VBA (Vision Benefits of America) VSP (Vision Service Plan) Great! Let's figure out if we accept your Medical Plan. Select one from the list below: Aetna Cigna BCBS/Anthem Humana United Health Care Kaiser Permanente PHCS/Multiplan Other Other 2. Have you signed up for an Advantage plan? (This is different from a supplement plan) Yes No Your Advantage plan has replaced your Medicare and your coverage and rules are specific to the plan you've selected. Please see the Medicare Advantage section for coverage, costs and network statusYou have indicated that you have MedicareNote: If Tricare has indicated “DIRECT CARE ONLY” they will not cover any exams regardless of the purpose or reason. If you are unsure of this status, please contact Tricare directly at (999) 999-9999Did the service member serve in: One of the armed service branches? The Guard/Reserves? Which of the following Tricare Plans are you using? Prime Standard Select If you are unsure of which coverage type to select, you can find out here: https://infocenter.humana-military.com/beneficiary/service/Account/LoginAre you/the patient: The service member? A family member? We are not providers for any Georgia state Medicaid insurance plans. These include: Care Source, Peach State, and Amerigroup. If you would like to understand how much you can expect to pay in our office, please go to the Price Predictor tool and indicate “Cash Pay.” We are in-network providers for most plans with this insurance. However, there are some commonly performed procedures routinely done in our office that this insurance will NOT cover. These procedures are seen as imperative to our doctors’ standard of care and are sometimes required for the most accurate diagnosis of your condition. We are in-network providers for most plans with this insurance. However, there are some exceptions. Does your insurance card have ANY of the following on it? Health Spring HMO No. My card does not indicate any of these plans We are in-network providers for most plans with this insurance. However, there are some exceptions. Does your insurance card have ANY of the following on it? EPO (Exclusive Provider Organization) HMO (Health Maintenance Organization) Pathway X No. My card does not indicate any of these plans We are in-network providers for most plans with this insurance. However, there are some exceptions. Does your insurance card have ANY of the following on it? Core Charter HMO No. My card does not indicate any of these plans We are not providers for this insurance. We cannot bill them on your behalf. You must see a Kaiser Provider to utilize your insurance. If you would like to understand how much you can expect to pay in our office, please go to the Price Predictor tool and indicate “Cash Pay.”
