Patient information

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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


Please note that full payment of co-pays, overages, non-covered items, etc. is required at the time services are rendered. Verification of eligibility and authorization numbers from your insurance company is not a guarantee of payment. The final determination of payment is made when the insurance company receives your claim. Any fee that your insurance does not cover is your responsibility. If insurance reimbursements are not made back to our office within 30 days, then the entire balance becomes your responsibility. Please understand that insurance filing is a courtesy, and you are ultimately responsible for knowing your insurance benefits.

Per the Department of Health & Human Services Evaluation and Management Services Guide, “There are three key components when selecting the appropriate level of E/M service provided: history, examination, and medical decision making. Visits that consist predominantly of counseling and/or coordination of care are an exception to this rule. For these visits, time is the key or controlling factor to qualify for a particular level of E/M services”. So, if you would like to speak to the doctor regarding something, even if an examination is not performed during that time, an office visit will be charged for the doctor’s time as stated in the Evaluation and Management Services Guide from the Department of Health & Human Services.

A refraction may be performed to evaluate if any further visual improvement can be achieved during a medical office visit. However, the refraction is considered a non-covered service by Medicare and medical insurances. The refraction fee is in addition to the fee for medical office visit and is in addition to your co-pay, and must be paid before the patient is seen by the doctor.

If using insurance, I hereby authorize the provider to release any information required to process my insurance claim. I also authorize my insurance benefits to be paid directly to Bright Eye Care & Vision Development. I understand that I am fully responsible for any fees that my insurance will not pay. Regardless of whether I am using insurance, I also understand and agree that no refunds will be given for any product, whether I pick up the product or not, or service because of the personalized nature of healthcare. I also understand and agree that there is no warranty or refund on broken or lost eyewear. I also agree and understand that there are no refunds for services or products. I agree to and understand all that is written in this document, and understand that this document holds true beginning today and for all subsequent visits and transactions in the future.

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What is the major purpose of this visit?:

This will help determine what type of exam you will need. If you are here for a medically related issue - red eye, painful eye, etc… - then you will need an office visit. If you are here to check for the need for glasses, then you will need a yearly eye exam. If you need a contact lens exam, then that would be a different type of exam. Each type of exam requires a different fee. Please direct any questions about fees to the front staff. The doctors will not discuss fees.


Dilation during a routine yearly eye exam does not check for eye diseases because those conditions are not routine. If you have a known eye disease or a medical concern involving the eyes, separate diagnostics and medical decision-making will necessitate a medical office visit as opposed to a yearly eye exam with dilation to investigate the disease process or concern. For example, if you are concerned about diabetes in the eye, you will need to schedule a medical office visit with us rather than just receiving a dilation with your yearly eye exam. Once dilated, you will be sensitive to sunlight and will not be able to read clearly for the next four to five hours. A pair of temporary sunglasses will be provided to help reduce sensitivity to light.

I understand & agree with the above statement.

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