Established Patient Medical Paperwork

I hereby authorize the doctors and staff of [location get='name'] to examine and treat me (or the minor patient named above). I understand that this examination may include, but is not limited to, a comprehensive evaluation of my ocular health and visual function. I understand that I may be referred to another healthcare provider if medically necessary.

I authorize the release of any medical or other information necessary to process my claims and agree to pay for any charges not covered by my insurance. I understand that my insurance benefits, if any, are an estimate and not a guarantee of payment.

A refraction is the test used to determine your eyeglass prescription. This service is not covered by medical insurance (including Medicare and Medicaid) and will be billed as a separate fee. By signing below, I acknowledge that I have been informed of this policy and agree to pay the refraction fee at the time of service.

Refraction allows us to determine the corrective lens prescription needed to optimize your visual acuity. This is a routine part of a comprehensive eye exam and is necessary for the prescription of glasses or contact lenses.

I acknowledge that I have been offered a copy of [location get='name']'s Notice of Privacy Practices, which describes how medical information about me may be used and disclosed, and how I can get access to this information. I understand that [location get='name'] has the right to change its privacy practices and that I may request a current copy at any time.

Authorization to Release Information to Family/Friends: I authorize [location get='name'] to discuss my health information with the following individuals (please list names and relationship):

A contact lens evaluation is a separate service from a routine eye examination and includes the fitting, training, and follow-up visits necessary to ensure a proper and comfortable contact lens fit. This service is not covered by most medical or vision insurance plans and will be billed as a separate professional fee.

By signing below, I acknowledge that I have been informed of the contact lens evaluation fee and agree to pay this fee at the time of service. I understand that the fee is for the evaluation services and does not include the cost of the contact lenses themselves. I also understand that a valid contact lens prescription requires a successful evaluation and follow-up visit.

Dilating your pupils allows your doctor to thoroughly examine the internal structures of your eyes, including the retina, optic nerve, and blood vessels. Dilation is an important part of a comprehensive eye exam and can help detect conditions such as glaucoma, diabetic retinopathy, macular degeneration, and other eye diseases.

Please note: Dilating drops may cause temporary blurry vision and light sensitivity lasting 2–4 hours. You may need someone to drive you home. Sunglasses are recommended.

Please select one of the following options regarding dilation today:

Optomap retinal imaging is an advanced technology that captures a wide-field digital image of the retina in a single, painless scan — without the need for dilation in many cases. The Optomap image provides a permanent record of the health of your retina and helps the doctor detect early signs of retinal disease, glaucoma, macular degeneration, diabetes-related eye changes, and other conditions.

Important: Optomap is an elective, non-covered service. There is an additional fee for this service that is not covered by insurance. You will be informed of the current fee by our staff.

Please select one of the following options:

I authorize [location get='name'] to bill my insurance company on my behalf for services rendered. I understand that my insurance coverage is an estimate and not a guarantee of payment. I agree to pay any balance not covered by my insurance, including but not limited to: deductibles, co-payments, co-insurance, and non-covered services.

I understand that it is my responsibility to know my insurance benefits and to ensure that [location get='name'] is a participating provider with my insurance plan. If my insurance does not cover any services rendered, I agree to be responsible for the full amount owed.

I also authorize the release of any medical records or information necessary to process my insurance claims. A photocopy or electronic copy of this authorization shall be as valid as the original.

Thank you for completing this form. Our team at [location get='name'] will review your information prior to your appointment. If you have any questions, please call us at [location get='primary_phone_number'].