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Home » Annual Exam Consent Form

Annual Exam Consent Form

FINANCIAL AND OFFICE POLICIES ASSIGNMENT OF BENEFITS

Please read and sign in the space provided
MM slash DD slash YYYY
Print Patient name(Required)
DOB(Required)
I have requested and consent to treatment from Advanced Eye Group, LLC
We require you to bring your INSURANCE card and ID to every office visit. It is your responsibility to keep us informed of any changes to your address, phone, or insurance information.

PATIENTS WITH INSURANCE:

  • If you do not inform us you have a vision/medical insurance plan(s), we will assume there is none.
  • Your insurance policy is a contract between you and your insurance company. The ultimate responsibility for all charges regardless of what your insurance does/does not pay is yours including but not limited to deductible, coinsurance or copay.
  • We do not guarantee the accuracy of benefit information received by the insurance companies
  • This office, with NO EXCEPTIONS will not back date, post authorize, or refund fees after services are rendered due to lack of notification of vision/medical benefits
  • it's your responsibility to obtain any insurance referrals (if required) from your primary care Doctor. If a referral has not been obtained PRIOR to your visit, your appointment will be rescheduled (or you may pay out of pocket fees).
  • You may file my own claim if you discover you have vision or medical benefits after services/products are rendered

MINOR/DEPENDENT CHILDREN:

  • An adult guardian must be present to sign any legal documents/forms and be able to make decisions on the child's behalf
  • In cases of separation or divorce, that person must be prepared to supply the SUBSCRIBER name, DOB, social security number (or last 4#), address and phone. If we do not have this information, the visit will be out of pocket

PATIENTS WITHOUT INSURANCE:

  • Identification must be presented each visit. Payment is due at the time services are rendered.

AUTHORIZATION TO RELEASE INFORMATION: I authorize the release of any medical information to my insurance carrier or a licensed physician or health-care provider concerning my illness and treatment. I also request payment of my insurance benefits to Advanced Eye Group, LLC.
APPROVED HIPAA CONTACTS: (Except your Doctors) With whom may we release information to? Please List Below. (If the end date is left blank, the duration is indefinite unless revoked in writing.)
Name
Name
HIPAA ACKNOWLEDGEMENT: have been presented the Notice of Privacy Policy of Advanced Eye Group, LLC and have been offered a copy of such policy to keep for my records.
Representative name (if other than patient PRINT

PROFESSIONAL SERVICES AND FEES

REFRACTIONVision test: Part of a Routine examto determine your prescription for the best possible vision.
  • NOT covered by most medical insurances
  • $37 fee is collected at time of service and is in addition to any copay
    As part of the Comprehensive eve exam, it is recommended ALL PATIENTS have the internal health of the eye thoroughly evaluated every year. This is best done by Dilation/Optomap
    DILATION: Eye drops to enlarge the pupils to examine the retina/back of the eye.
    • IS COVERED by medical insurances
    • Will have blurred vision and light sensitivity for 4-6 hours.


    OPTOMAP DIGITAL IMAGING: A high resalution image of the retina/macula. It becomes a permanent part of your medical record for comparison for changes over time.
    • NO BLURRINESS OR LIGHT SENSITIVITY
    • NOT covered by any insurance
    • $37 fee in addition to any copay and refraction fees
    • Dilation may still be required in some instances
    CONTACT LENSES: are medical devices worn on the eyes.
    • Federal regulations require an evaluation and prescription ANNUALLY to avoid infection/injury and to assure the pest fit and vision. Federal regulations stipulate a contact lens prescription is valid for 1 year.
    • Evaluation fee is separate from copayirefraction fees and is collected at the time of service.
      • EVAL: $35 (same brand/type of lens}
      • REFIT: $59-399 (new brand/type of lens)
      • NEW FIT $159-$199 Initial fitting and training. Trial lenses and follow ups included
    • Contact lens supply is NOT included
    I understand the above policies/fees and take full responsibility for any activities I may perform after dilation.
    Please check all that apply
    Patient name (print)(Required)
    MM slash DD slash YYYY
    Representative name (if other than patient PRINT)