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Medical History
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Eye History
Contact Lens Wearers only:
Medical History:
Do you have any of these medical conditions?
Family Medical History
Does anyone in your family have any of these medical
conditions?
Family Eye History
Does anyone in your family have any of these eye
conditions?
Review Of Systems
Social History
HIPAA Notice of Privacy Practices
NOTICE OF PATIENT PRIVACY RIGHTS, PROTECTION, AND RESPONSIBILITIES
SERVICES PROVIDED WITHOUT REFERRAL AUTHORIZATION
As a member of a vision care program, I acknowledge for today's visit that I will assume
full financial responsibility for services rendered to me if my vision insurance carrier
denies or does not cover my claim for these services.
MEDICAL NECESSITY
If my insurance determines that a medical service and/or material are not covered, I
acknowledge that I have been notified and will assume full responsibility for the
service(s) and/or material stated below.
COPAYS
I understand that I am responsible to pay all co-payments at the time of services, prior
to leaving. Co-payments cannot be waived at any time by the provider of service or Pilot
Point Family Eye Care.
DEDUCTIBLES
If my insurance determines that I have not met my deductible, I understand that I will
be fully responsible for payment in a timely manner, no more than 30 days after I have
been notified by insurance and/or provider. Yearly deductibles cannot be waited at any
time by Pilot Point Family Eye Care.
PROFESSIONAL SERVICES AND MATERIALS
I understand that I am responsible for 100% of all professional fees rendered on the
date of services. I understand that I am also required to make payment for 100% of
materials at the time materials are ordered. If I am supplying my own frame, I
understand that many plastic and metal products may weaken over time and I will not hold
Pilot Point Family Eye Care or my insurance carrier responsible for accidental
laboratory breakage. If I do not pick up my materials within 60 days from my initial
order, my materials will be returned to the laboratory, and my payment will not be
refunded. If I am to receive contact lenses by mail, I understand that I am required to
pay in full at time of services.
Our Patient Satisfaction Guarantee applies to single vision and progressive lenses. We
use only premium single vision optics and premium progressive addition lenses, otherwise
known as no line bifocals. Less than one percent of our patients have difficulty
adapting to our premium progressive lenses. We will remake a non-adapt progressive lens
or single vision lens one time, in the same frame. If it is still unsatisfactory, we
will replace it with a lined bifocal or a single vision lens, in the same frame. While
we make every attempt to solve these rare issues, no refunds will be given in a case
where a patient does not adapt to a progressive lens or single vision lens.
HIPAA
I understand that under the Health Insurance Portability and Accountability Act of 1996
(HIPAA), which I have been provided a copy, that I have certain rights to privacy
regarding my protected health information. I understand that this information can and
will be used to conduct, plan and direct my treatment and follow-up among the multiple
healthcare providers who may be involved in that treatment directly and indirectly,
obtain payment from third party payers, and conduct normal healthcare operation such as
quality assessments and physical certifications.
Important Information Regarding Your Upcoming Appointment
At Pilot Point Family Eye Care, we are dedicated to preserving your eye health,
improving your vision and maintaining your systemic health. Please call us 24 hours in
advance of your appointment if you are unable to follow the requirements below.
- We require that all patients receive the digital retinal imaging and
ocular
coherence tomography examination for $34.
• We have heavily invested in state-of-the-art technology to
maximize your experience and provide the highest quality of care. This test
is
mandated
as we believe it is the best way to evaluate your ocular health and is
considered
standard of care at our practice. Our imaging system captures a
high-definition
image of
your retina and a 3-dimensional cross-sectional scan of the tissue in the
back
of
the
eye. This technology allows us to detect underlying eye diseases that may
not be
visible
during a normal comprehensive examination. If you cannot afford the $34,
please
inform our office staff prior to your appointment by phone or email.
- We highly recommend that you have your eyes dilated. Dilation
allows for the
most thorough evaluation to assess your risk for eye conditions such as glaucoma,
macular degeneration, diabetes, retinal tears or detachments and other disorders which
may not have symptoms. If you refuse dilation, there is a much greater chance that an
eye disease could remain undetected. Dilating drops have few side effects, all of which
last approximately four hours. These include blurry near vision and increased
sensitivity to sunlight. Blurry distance vision may occur, but most patients usually
feel comfortable driving with their glasses or contact lenses. There is no additional
fee for dilation. If you refuse dilation and an eye condition is suspected, the
doctor will request that you return for an additional visit where dilation will be
required.
- If you have any of the following symptoms: fever, cough, chills,
shortness of
breath, muscle pain, sore throat, if you have been diagnosed or exposed to anyone with
known COVID-19 in the last two weeks or have traveled internationally in the past two
weeks, please reschedule your appointment.
Thank you in advance for understanding, we want to provide the best possible care while
keeping everyone safe.
The Pilot Point Family Eye Care Team.