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Patient Information

After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

First name, last name, and cell phone are required.

Name

First *

Last *

Suffix

Address

Address line 2

City

State

Zip Code

Contact information

Other Phone

Cell Phone *

Preferred Contact Method

Birthday

Sex

Male Female

Misc/Guardian

Billing Information

Complete the billing information from the original form.

Billing address is different from the patient address

First

Last

Suffix

Address

Address line 2

City

State

Zip Code

Home Phone

Medical History

Please choose from the menu options or select âOtherâ to enter your own text. Thank you!

Eye History

Reason for Visit

Do you currently have any of these symptoms?

Have you had any eye surgeries? Please describe

Last Eye Exam

Primary Vision Correction

Medical History

Medications No Meds Used

Drug Allergies No Known Drug Allergies

Primary Care Physician

Last Visit

Reason

Pregnant Or Nursing

Do you have any of these medical conditions?

Diabetes

High Blood Pressure

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Other

Family Eye History

Does anyone in your family have any of these eye conditions?

Macular Degen

Glaucoma

Retinal Detach

Cataracts

Lazy/Crossed Eye

Blindness

Social History

Hobbies

Smoking Status

Type

Alcohol Use

Type

Illegal Drug Use

Type

Submit Form / Signatures

Review the insurance information, consent, and retinal imaging choices from the original form.

About Your Insurance

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

Medical insurance (such as BCBS and Medicare) must be used if you have any eye health problem or systemic health problems that has ocular complications. Your doctor will determine if these conditions apply to you.

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.

Guarantor (Responsible Party)

Name

Date Of Birth

Primary Vision Insurance

Company Name

Policy ID No.

Primary Medical Insurance

Company Name

Policy ID No.

Medical Insurance Policy

As part of our services at this practice we are happy to assist you in determining the benefits of your individual policy and in collecting your reimbursement of insurance benefits for medical services. To avoid any misunderstandings please read the following statements carefully.

The legal obligations of your insurance provider are between yourself and your provider, not between this practice and your provider.
When your insurance provider(s) has settled your planâs covered items, you will be notified by a monthly statement if there were any unpaid balances. Unpaid balances can include non-covered items or series, co-pays, deductibles, lapses, ineligibility or termination of coverages. Unpaid balances are the sole responsibility of the patient.
To keep the cost of records and collections down any patient portion amounts on your order will be due at the time of service.
I authorize the use of this form on all insurance submissions as well as authorizing the release of information to all my insurance companies as well as allowing the doctor to act as my agent to help me in obtaining payment from my insurance companies.
I authorize payment to be made directly to the provider and permit a copy of this authorization to be used in place of the original.

Consent for Treatment

I hereby provide authorization to administer diagnostic and medical procedures as may be necessary for proper health care. I acknowledge that I am able to obtain Clarifeye Total Eye Careâs Notice of Privacy Practices and release the right to file insurance given.

Patient Signature (or parent/guardian signature if patient is a minor)

Date

Retinal Imaging Consent Form

Our office offers Digital Retinal Imaging. This non-invasive imaging test allows the doctor to see a much more detailed view of the retina than with traditional methods. The image becomes a permanent part of your medical file, allowing the doctor to make important comparisons year over year. In many cases, there will not be a need to dilate after this process. If the doctor decides that there is a need for dilation, this will be discussed during your exam.

These images will help see early signs of many ocular and systemic diseases such as:

Glaucoma
Age related macular degeneration
High blood pressure
Diabetes
Retinal holes or detachments

Either traditional dilation OR Retinal Imaging ($35 fee) is an essential part of your comprehensive eye exam and is prescribed for all patients once per year.

Please check one of the following:

YES: I understand the importance of Retinal Imaging and would like to have it performed ($35 fee) NOT SURE: I would like to discuss with the doctor first. NO: I elect to have my eyes dilated (no additional charge). I understand that it will cause light sensitivity and may blur my vision for about 2-4 hours. I decline both dilation and Retinal Imaging and understand that a comprehensive examination has not been performed. I understand that I am assuming all risks associated with failure to diagnose conditions, which may have been provided by these tests.

Patient Signature

Date

Additional Documents

Please review each document below, sign on the signature line, and confirm the date before submitting.

Verification

Please add the numbers above together.