Submit Form / Patient Signatures
PLEASE READ THIS ELECTRONIC SIGNATURE CONSENT BEFORE YOU PROCEED. Your electronic
signature
shall
have the same force and effect as an original signature and shall be deemed
(i) to be "written" or "in writing" or an "electronic record"
(ii) to have been signed and
(iii) to constitute a record established and maintained in the ordinary course of business and
an
original written record when printed from electronic files. Such paper copies or "printouts," if
introduced as evidence in any judicial, arbitral, mediation or administrative proceeding, will be
admissible as between the parties to the same extent and under the same conditions as other original
business records created and maintained in documentary form.
Retinal Examination:
An important part of your eye exam is the retinal evaluation. It enables the doctor to evaluate the health of your body by looking at the blood vessels, nerves, and other layers inside your eye. This evaluation is mandatory for all patients.
Please select one of these two options:
* Please check one of the two checkboxes below
I understand that my routine vision examination will include
Optomap retinal imaging. I agree to the
$39.00 fee for service which is not covered by my insurance. This is a painless procedure that allows the doctor to view structures inside the eye without the use of eye drops or lingering side effects. (This is a mandatory
standard of care procedure for all patients over the age of 5. We will be unable to conduct an examination on any patient that refuses this procedure.)
I would like a
Total Wellness Scan that includes Optomap retinal imaging and baseline testing for Macular Degeneration and Glaucoma using Ocular Coherence Tomography. I agree to the
$59.00 fee for service. I understand that this technology is not covered by my insurance. (Richmond Location Only).
Examination and Billing Protocols
• Payment is due in full at the time of service and purchase. Payments made toward services
offered at Elite Family Vision and Richmond Eye Experts are non-refundable.
• You must present your insurance information before or on the day of your visit. The decision to
bill your
vision insurance vs. your medical insurance depends on the reason for your visit and
severity
of eye condition when you present for your exam.
• Your complete comprehensive eye exam will be conducted at the time of your appointment.
Declining the internal eye exam will require a signed consent and is NOT ADVISED. Delaying the internal
eye exam to another day will incur an additional office visit fee of $50.00.
• Contact Lens exams will involve additional fees. These fees are dependent on your insurance
company. Please ask the staff for details.
If you sign up for a contact lens exam, this fee will be
collected even if you do not purchase the lenses, or complete the fitting process. Contact Lens
exams
may require follow up exams on a separate date for no extra charge. Follow up exams should be
maintained
as scheduled, and prescriptions should be finalized within 60 days of the initial visit. If the
process
takes longer due to noncompliance with follow up exams, then there will be an additional contact
lens
examination fee payable by the patient.
INITIAL HERE:
Optical Policies
• If you are not comfortable with your glasses, we will do
one complimentary prescription
recheck
within 60 days of the initial eye exam.
• Rechecks and Remakes will NOT be provided after 2 months of the exam. This will be considered a new exam and new eyewear purchase.
• A $25 Warranty is available for your eye wear purchase. This warranty will cover ONE replacement
of frames and/or lenses with applicable copays. Please ask associate for details. (Richmond Location Only)
• Any payment made toward Custom Eyewear at Richmond Eye Experts is non-refundable. (Richmond Location Only)
• If you wish to change your frame, there will be a charge of $100.00 plus the cost difference
between the frames. (Richmond Location Only)
• If you wish to change your lens treatments, a new lens will be provided at a discounted rate. (Richmond Location Only)
INITIAL HERE:
Patient Owned Frames-Richmond location only
• We are not liable for any damage that your frame may incur. We can only guaranty the quality and
durability of the frames from our optical. We recommend a frame from our in-house collection which will
be warrantied for breaks or damage. Used, old, or non-optical frames are more likely to bend or break
during lens insertion.
• Your frame may be discontinued by the manufacturer in which case we will not be able to order the
same one for replacement.
• If your frame breaks during handling, new lenses will be provided at a discounted rate. The
purchase of the new frame will be at your expense.
INITIAL HERE:
Notice of Privacy Practices: PLEASE READ CAREFULLY
• We will use your health information for referrals to other physicians for your continued care,
to provide appointment reminders, prescribe or recommend treatment alternatives, and provide information
about health benefits and services that may be of interest to you.
•
We will email your prescriptions and referrals via the patient portal to the email address you
have provided on this form. We are unable to merge portals or change email addresses over the
phone.
• Please review the
complete patient privacy notice. Signing this document acknowledges that you
were offered the opportunity to review this policy.
INITIAL HERE:
Authorization and Consent: PLEASE READ CAREFULLY
• I certify that I have filled out the patient information form accurately and to the best of my
knowledge.
• I authorize the eye doctor to release any information including the diagnosis and records of any
care rendered to me, to third party payers/ health practitioners for the purposes of checking
eligibilities, payment or continued care.
• I attest that the address, phone number, and email address provided is mine, and Elite Family
Vision or Richmond Eye Experts can contact me to remind me of appointments, mail patient information
including prescriptions, Optomap images, and balance payable notices to any of the above.
•
I authorize and request my insurance company to pay directly to the eye doctor, the
benefits otherwise payable to me. I understand that my insurance carrier may pay less than what
is billed, and I may be responsible for uncovered balances, copays, coinsurance payments or
deductibles that are not covered under insurance contracted amounts.
INITIAL HERE:
• I understand that if the insurance company accidentally pays me directly for the services, I will
issue a payment to the billing facility.
• I understand that I will not receive prompt pay discounts or special pricing when I use my
insurance for payment toward the eye exam.
• I understand that there are no refunds for professional services rendered. Prescription glasses
are custom made products, and as such, once the order is transmitted to our lab, it cannot be cancelled
or refunded at any time.
• I hereby authorize Elite Family Vision PLLC or Eye Experts PLLC (DBA Richmond Eye Experts) to
bill my vision and/or medical insurance on my behalf and collect payment for services rendered.
•
I understand that balances will be forwarded to a collection agency if not paid within 90
days after three attempts to contact me via phone, text, or email. An additional administration
fee of $25 will be added to bills that require to be mailed.
INITIAL HERE:
• I understand that this office is HIPAA compliant and acknowledge that the HIPAA policies are
available
here. This authorization and consent to use my Protected Health Information is
valid for 6
years until revoked in writing.
• I understand that Elite Family Vision or Richmond Eye Experts may refuse treatment if I do not
consent to the above protocols, notices, and authorizations
ELECTRONIC SIGNATURE:
Date: