Online Patient Forms

Patient information

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Billing information

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Primary Vision Insurance

Insurance Information

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Primary Medical Insurance

Insurance Information

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Insurance Policy Group:

Not Primary On Account: Not Primary

Name:

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Spouse Child Other

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Policies, Consent, Submit Data

FINANCIAL DISCLAIMERS
We will attempt to verify your insurance eligibility for services and/or materials before your appointment. Verification of eligibility is done as a courtesy only and is not a guarantee of payment. Please check with your plan administrator if you have any questions regarding your eligibility.

Initial

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LIABILITY
I understand my provider will bill my vision and/or health insurance. I know that I am responsible for any remaining balance after the claim is submitted. Should my insurance not cover the services that are submitted in full, I agree to pay any outstanding balance.
In cases of divorce, the individual who receives the care is responsible for all charges. We will not bill a divorced spouse for the patient's services. For minor patients, the responsible party bringing the minor patient to the clinic will be responsible for any co-pays or co-insurance at time of service.

Initial

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PRIVACY POLICY View Notice of Privacy Practices
In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for services, and to conduct health care operations involving our office. The Privacy Policy describes these uses and disclosures in detail. I acknowledge that I have been offered and/or received a copy of the Privacy Policy.

The following people are authorized to speak on behalf of my account / treatment plan:

Initial

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Name

Relation To Patient

Phone #: Account / Treatment Plan

Name

Relation To Patient

Phone #: Account / Treatment Plan

REFRACTION FEE (MEDICARE/MEDICAL INSURANCE ONLY)
The part of your examination that determines your prescription is called a refraction. A refraction is also done under certain circumstances for diagnostic purposes. If you have routine vision benefits such as VSP or EyeMed, your refraction is typically included with your exam benefits. Medical insurances that do not include routine vision benefits, such as Medicare, do not cover a refraction. The fee for a refraction is $42.

Initial

RETINAL HEALTH SCREENING

The Optomap retinal health screening allows our doctors to provide the highest level of care and is mandatory for all new patients (age allowing). This screening enables us to detect retinal disease at an earlier state making it essential in the prevention and management of eye health for our patients. The fee for this screening is $39. Currently, there are few vision insurances which pay for this screening. Your provider will bill your vision insurance when applicable.

Initial

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CONTACT LENS EVALUATION FEE (CURRENT CONTACT LENS WEARERS ONLY)

The contact lens evaluation is separate from the health portion of your examination and requires an additional prescription. This fee includes the additional testing, fitting assessment, and new contact lens prescription which allows you to purchase contact lenses for up to one year from the date of the evaluation. Fees for the contact lens evaluation starting at $80, however most vision insurances have a specified copay dependent upon your contact lenses.

Initial

Glasses | Contact Lens Prescription

Initialing below acknowledges that you understand that you will receive your glasses and or contact lens prescription at the end of your exam. Your glasses prescription will also be available through your patient portal.

Initial

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We Will Not Receive Your Information Until You Press The Green Submit Button Below.

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Patient information

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Primary Vision Insurance

Primary Medical Insurance

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