Skip to main content
Electric Rd, Roanoke
540-274-0300 x1
Valley View, Roanoke
540-274-0300 x2
Tanyard Rd, Rocky Mount
540-274-0020
Open Menu
Close Menu
Phoropter
Home » Contact Us » Patient Forms

Patient Forms

KARTESZ EYE CARE INC. PATIENT INFORMATION

  • Please choose the office for which you are a patient
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

  • INSURANCE INFORMATION

  • Date Format: MM slash DD slash YYYY

  • Date Format: MM slash DD slash YYYY

  • FINANCIAL POLICIES

    PLEASE INITIAL AND SIGN THE SIGNATURE LINE BELOW
  • Payment is due on the day of service. All co-pays, non-covered services and materials and co-insurance amounts are due on the day of service. You must present a current insurance card and identification at the time of service.
  • Referrals are to be obtained by the patient from their primary care provider and must be presented before services are provided. 1 will be responsible for charges to my family or me. If my account is sent to collections, all costs associated with collection or legal actions, including a 33 1/3 % attorney fee will be due from me. Materials not picked up within 90 days of notification will be returned to stock or donated. All monies paid will be forfeited.
  • We have a no return policy. All prescriptions glasses and contacts are made to order. We do stand behind our services.
  • Our office participates with both medical and vision plans. in the event that your exam is billed medically and there is a remaining balance, we will first exhaust your vision plan benefits before transferring any balance to your account. I authorize the release of any medical or other information necessary to process a claim for services. I also request payment of government benefits either to myself or to the party who accepts assignment. I authorize payment of medical benefits to the undersigned physician or supplier for services provided today.
  • HIPAA Acknowledgement Receipt: The offices of Dr. Andrew Kartesz, O.D. and Associates have provided me with a copy of their HIPAA Policy. (HARD COPY AVAILABLE UPON REQUEST)

  • Dr. Kartesz requires all his patients to have a retinal photo. He feels it is necessary to ensure proper diagnosis that can sometimes go undetected in a routine eye health exam. This test takes a 200 degree image of the back of the eye. In most cases, you will not have to be dilated today. The fee is $20.00. If the doctor finds a medical reason for the photo, we will bill your medical insurance.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY