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Billing information

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Primary Vision Insurance

Primary Medical Insurance

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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

Policies, Consent, Submit Data


Within The Last 14 Days Have You Experienced Any Of The Following Symptoms:

Condition Yes No
Shortness Of Breath Or Difficulty Breathing
Repeated Shaking With Chills
Muscle Pain
Sore Throat
New Loss Of Taste Or Smell
Have You Traveled In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared For Someone Diagnosed With COVID-19 In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared For Someone With A Presumptive Positive Case Of COVID-19 In The Last 14 Days?
Has Anyone In Your Household Been Asked Or Required To Quarantine Based On Contact With A Person Who Has A Confirmed Or Presumptive Positive COVID-19 Test Result Or Diagnosis, Or Have You Been Asked To Quarantine?

Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

Notice of Privacy Practices

View Notice of Privacy Practices Form

Patient Responsibility

There are two types of health insurance that will help pay for your eye care services and products. You may have both and our practice accepts both:

-Vision care plans: such as VSP and EyeMed
-Medical insurance: such as Blue Cross/Blue Shield and Medicare

Vision care plans only cover routine vision exams along with eyeglasses and contact lenses. Vision plans only cover a basic screening for eye disease. They do not cover diagnosis, management or treatment of eye diseases.

Medical insurance must be used if you have any eye health problem or systemic health problem that has ocular complications. Your doctor will determine if these conditions apply to you, but some are determined by your case history.

If you have both types of insurance plans it may be necessary for us to bill some services to one plan and other services to the other. We will use coordination of benefits to do this properly and to minimize your out-of-pocket expense.

We will bill your insurance plan for services if we are a participating provider for that plan. We will try to obtain advanced authorization of your insurance benefits so we can tell you what is covered. If some fees are not paid by your plan, we will bill you for any unpaid deductibles, co-pays or non-covered services as allowed by the insurance contract. For glasses orders, once your order is finalized, full payment of the glasses is expected at the time of service. Once the order is submitted to the lab, lens changes and refunds are not allowed. Thank you for allowing us to serve your eye care needs.

I have read and agree with these policies.

Reviewed HIPAA Notice of Privacy Practices:

1) Dilation Consent Form

Dilation is an important and recommended part of a comprehensive eye examination. Dilation is a procedure in which drops are instilled in each eye to increase the pupil size; this allows the doctor to conduct the most thorough examination of the internal health of your eyes. Dilation can aid in diagnosis and early detection of the following:

•Systemic Diseases, such as diabetes, high blood pressure, cancer, systemic infections, autoimmune disorders, etc. that can affect the eyes without obvious symptoms to the patient.

•Physical Changes and Diseases of your Eyes, such as cataracts, glaucoma, retinal holes/tears/detachments, neoplasms, macular degeneration etc. that can affect your vision.

Dilation will make reading up close difficult and lights seem brighter than usual. The effects can last 3-4 hours, although it can last longer in some people. Most people will be able to drive once their eyes are dilated, as long as they have sunglasses.

It is highly recommended to have your eyes dilated if:

You are new to our office
You have a history of diabetes
You have a history of high blood pressure
You have a history of headaches or migraines
You have a history of floaters or retinal conditions.
You are over age 45
You have glasses or contact lens prescription over -4.00
You have been previously diagnosed with a condition in the back of the eye that needs yearly monitoring

If you do not fit in the above categories, it is still recommended to have your eyes dilated at least every two years.

The fee for this procedure is $20 and requires an additional 20 minutes of your time. Insurance or vision benefits/vision care plans do generally cover for this procedure.

Please check one of the following:

In refusing to have my eyes dilated, I understand that I am assuming all risks and responsibility associated with failure to diagnose eye conditions due to lack of information, which may have been provided by this procedure. If any condition arises in the future of which may have been detected through dilation, I will not hold Dr. ________________ and his/her staff responsible.

2) Optos Consent Form:

• Is fast, easy, and comfortable
• May alleviate the need for dilation
• Provides a permanent record for annual review
• Is recommended by your doctor annually

An optomap exam gives us a panoramic image of your retina. These images help the doctor assess the health of your eyes and check for conditions including macular degeneration, glaucoma, and retinal detachments. These problems can threaten vision without warning or symptoms.

Serious health problems unrelated to the eyes such as diabetes, hypertension, heart disease, some cancers, and auto-immune disorders, can also be viewed with an optomap exam. Early detection could help save your vision or your life.

The cost of the optomap retinal exam is $39