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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
Policy's and Signatures
CONSENT TO USE OR DISCLOSE HEALTH
INFORMATION FOR TREATMENT, PAYMENT & HEALTHCARE OPERATIONS
In the course of providing services
to you we create, receive & store health information that identifies
you. It is often necessary to use & disclose this health information in order to treat you, to obtain
payment for services & to conduct healthcare operations involving our office. We have comprehensive
notice practices that describe these uses & disclosures in detail.
Notice of Privacy Practices the use & disclosure of
your health information is necessary for you to receive follow up care from this office or another
health professional. Our Notice of Privacy Practices will be updated when our privacy practices changes.
Whenever our practices change you can get an updated copy here at our office or from
www.heightseyestudio.com website. When you sign this consent you signify you agree that we can & will
use & disclose your health information to treat you, to obtain payment for our services, & to perform
healthcare operations. You can revoke this consent in writing at any time unless we have already treated
you, sought payment for our services, or performed healthcare operations in reliance upon our ability to
use or disclose your health information in accordance with this consent. We can decline to serve you if
you elect not to sign this consent form. You have the right to ask us to restrict the uses or
disclosures made for purposes of treatment, payment or healthcare operations, but as described in our
Notices of Privacy Practices, we are not obligated to agree to these suggested restrictions. If we do
agree, however, the restrictions are binding on us. Our Notices of Privacy Practices describes how to
ask for a restriction.
Contact Lens Policy - (only
applicable if you will get contact lenses) The doctor
performs a comprehensive eye exam to check the overall health of your eyes, as well as additional
testing that determines the strength & type of contact lens that best suits your eyes. This includes a
pair of trial contact lenses & a 1-week progress visit to check the Rx & fit of your contacts. There is
a separate charge from the regular eye exam for a contact lens fitting that varies according to your
prescription. Fees that are paid for examinations, contact lens evaluation/fitting, & progress checks
for contacts lenses are non-refundable. A period of 30 days is allowed for all contact lens follow-up
visits. There will be a separate charge for any additional visits past the 30-day time frame. Your
prescription is finalized once you have worn the contacts & expressed to us that you would like to
proceed with the order. Once the order is placed, the contact lens companies do not take back the
contacts so we are unable to provide a refund for these boxes.
Insurance Services - As a courtesy to
our patients, we will file claims with insurance
companies. It is ultimately your responsibility for the full & timely payment on your account. Heights
Eye Studio will attempt to verify coverage & benefits prior to your visit with the physician. If we are
unable to verify benefits, we may ask you to pay in full or reschedule your visit until the verification
can be obtained. This verification will be used to estimate your financial responsibility; however, this
verification is not a guarantee by your health plan of coverage or payment. It is your responsibility to
know your health plan coverage. If your health plan denies any part, or the entirety of your claim, you
agree that you are financially responsible for the remaining balance.
Please be aware that certain office
products, procedures or services may not be
covered, or may be considered "not medically necessary" by your health plan. You are responsible for
payment of these services. Such procedures & products include but are not limited to: contact lens
fittings, specialty contact lenses, specialty eyeglass lenses & designer frames, punctual closures,
optomap, glaucoma scans, visual fields or other medically necessary testing. You will be billed if we
obtain a denial from your insurance company &/or we have not received payment from the insurance company
within 60 days of our filing your claim. Failure to pay amounts owed to Heights Eye Studio may result in
you being referred to a collection agency & an entry may eventually appear on your credit report.
Product Policy - If you purchase
glasses, contact lenses, or other supplies from our
offices, please understand that the products/supplies are non refundable. All materials are to be paid
in full prior to ordering. If there is a balance due for any other service or material purchase from a
previous date, it must be paid prior to ordering new product. Patients who order progressive lenses &
then have difficulty adapting to them will be allowed a one time remake to single vision lenses. We do
not offer refunds on the difference between the costs of a progressive lens & a single vision lens, nor
for a higher priced frame that is restyled into a lower priced frame. This is a courtesy remake & goes
above & beyond what is allowed by most insurance companies. A shipping charge of $15 is required when
ordering out of stock frames, including warranty replacements. Some exclusion may apply.
CALL TO ACTION POLICY:
Please sign here to opt-in to our
text messaging/SMS program that will include, but may
not be limited to, appointment reminder, billing and promotionally related messages. Messages should not
arrive at an average rate of more than 1 per week. Depending on your carrier and plan, certain text
messaging fees may apply.
Please sign here to give Heights Eye
Studio permission to use my name as well as any
quotes, photographs, videos, or voice recordings that I am part of for the purpose of public relations,
marketing, fundraising, or other communication purposes including, but not limited to, press releases,
articles, publications, websites, or social media channels. I hereby waive all claims and rights to the
above stated multimedia and give my express authorization for those images, videos, and voice
recordings, as well as my name and likeness, to be published or distributed to the general public and/or
utilized by Heights Eye Studio in promotional material.