SODO Vision - Patient Intake Form

  • Located inside SODO Costco, 4401 4th Ave S, Seattle, WA 98134

    Our office is NEXT to the Optical Department. Costco membership is not required for the exam. However, membership is required to purchase glasses/contact lenses.

  • If you need to cancel or reschedule, contact our office 24 hours before your appointment to avoid a $100 late cancel/no-show fee. Unfortunately, there are still too many people who make appointments and don't show up.

    Please arrive 10 minutes before your scheduled appointment, to allow time for parking/pre-testing.

  • PATIENT INFORMATION

  • Birthdate*
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  • Biological Sex*
  • OPTIONAL: preferred pronouns

  • If the patient is under 18, a guardian over 18 years old must be present at the exam or must call our office as soon as possible to give consent for the exam.

    If no parental presence or consent is given by the time of the exam, the appointment will be canceled, and a fee will be charged due to cancellation.

  • Please contact us if your child does not know their ABCs or numbers well. We may need to cancel this appointment and recommend a pediatric office.

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  • Billing information

    If checking with your insurance company, ask for SODO Vision Care, not Costco Optical.

  • ROUTINE WELLNESS EXAMS (ie your annual eye wellness check for glasses/contact lenses) are billed to vision plans.
    MEDICAL OFFICE VISIT (ie diabetic exam, red eyes, floaters/flashes, dry eyes, etc) are billed as medical visits to medical insurances - not vision plans.

    Extra exam services such as contact lens evaluations and Optos retinal photos are not billed to insurance. Patients are responsible for these service fees.

    We only bill your primary insurance. We do not coordinate with secondary insurances.

    If you don't see your insurance in the list, we may not take your insurance. You can also email your ID cards to info@sodovisioncare.com for us to check.

  • You selected Self-Pay / No Insurance Billed.
    We accept many forms of payment: cash, check, Visa, Mastercard, American Express, Discover, Mobile pay, and FSA/HSA.

    If you need an itemized reciept to submit a claim to your insurance, please request at the conclusion of your exam.

  • You selected Out-of-network Vision Service Plan.

    We want this to be transparent, we are out-of-network for your Eye Exam, so you'll pay a higher co-pay (plans vary but approximatley $65 for the wellness exam: additional services such as contact lenses, Optos photos, etc are patient responsbility not billed to your insurance).

    Many of our patients elect this route because:

    • we offer appointments within three days!
    • we provide great service! see our Google Reviews.
    • Costco Optical is in-network for your Materials: Glasses and/or Contact Lenses.

    You don't have to do anything. Our office will submit the claim.

  • The plan must be ACCESS PPO. We can not bill other Kaiser plans.

  • Refraction (ie determining your glasses prescription) is not covered.
    We do not bill HMO and Advantage plans.


    Note: Medicare is usually for patients over 65 years old. This it NOT Medicaid: we do not bill any Applehealth plans.

  • You selected an out-of-network plan we are not contracted with:

    Although we are out-of-network for your Eye Exam, we can still assist you to utilize some of your benefits. How this works:

    1. You pay for your full exam fees directly to our office
    2. We'll submit the claim to your plan
    3. After a 4-6 weeks, you'll receive a reimbursement check from your plan. The amount is less than an in-network exam but will allow you to utilize some of your benefits.

    Many of our patients elect this route because:

    • we offer appointments within three days!
    • we provide great service! see our Google Reviews.
    • Costco Optical is in-network for your Materials: Glasses and/or Contact Lenses.

    You don't have to do anything. Our office will submit the claim. You wait for the check.

  • Special Premera plans:
    Amazon's Premera medical insurance outsources vision benefits to VSP; please select VSP from the list.

    Microsoft's Premera medical insurance outsources vision benefits to Eymed; please select OUT OF NETWORK plans from this list.

    Plans with member ID# starting with "R" or say "Federal Employee Program Blue Vision" are not billable by our office.

    We can still bill Premera for medical office visits.

  • Spectera Vision is the only commercial United Health Care product we take.
    Includes: some Medicare AARP plans


    Medical exams are not covered by this vision plan.

  • Most Regence medical insurance plans outsource vision benefits to VSP.

    We want this to be transparent, we are out-of-network with VSP, so you'll pay a higher co-pay (plans vary but approximatley $65 for the wellness exam: additional services such as contact lenses, Optos photos, etc are patient responsbility not billed to your insurance).

    Many of our patients elect this route because:

    • we offer appointments within three days!
    • we provide great service! see our Google Reviews.
    • Costco Optical is in-network for your Materials: Glasses and/or Contact Lenses.


    You don't have to do anything. Our office will submit the claim.

  • RGA/HMA is not the same as Regence Blue Shield in this list.

  • Which Out-of-Network plan do you have?*
  • Are you the policyholder of the insurance?*
  • The policyholder is your:*

  • Policyholder Birthdate*
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  • Most Regence ID cards will show VSP on the back.

    This means your Regence plan outsources vision benefits to Vision Service Plan (VSP), which we are out-of-network with.

    Please read the VSP section for more info.

  • Regence Group Administrations (RGA) is not the same as  Regence.

    Do not select RGA if you have Regence.

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  • HEALTH HISTORY

  • Reason for appointment*
  • Have you worn contact lenses prescribed by an eye doctor before?*

  • 1st Time Contact Lens Wearer Exams require multiple visits including:

    • initial eye exam and review of contact lens pros/cons/options.
    • training session: to learn how to insert/remove/care for contact lenses, etc. (typically scheduled on another day)
    • any follow-up visits deemed necessary by the doctor, to ensure healthy eyes and addres any concerns.
    • once all steps are done, the doctor will release brand specific prescription(s) to buy contact lenses.
       

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  • Do you have diabetes or take medications for diabetes?*
  • Have you had a recent diabetic eye exam?*

  • For Medical Office Visits or Diabetic Eye Exams:

    These medical service fees are only billed to medical insurances, not vision plan used for annual wellness checks.

    These services do not include a prescription check for glasses and/or contact lenses. You may pay out-of-pocket for the prescription checks, or schedule another appointment to use your vision plan.

    Please contact our office if you need clarification.

  • I typically wear:*

  • Any problems with your glasses?*

  • The 'working distance' of reading and/or computer glasses is how far from your face that you like to perform these activities.

    Our standard measurement for near/reading/laptop activities is set for 16".

    Our standard measurement for desktop computer activities, is set for 24".

    If you prefer to hold objects outside of these standard working distances, please measure and provide that info below. Otherwise, your prescriptions may not work well.

  • Yes, I use the standard 16" and 24" distances.*

  • We only fit standard spherical rigid gas permeable lenses.
    A copy of your previous prescription would be exceptionally helpful.

    If you wear a astigmatism/bitoric, multifocal, keratoconus, orthokeratology, scleral, hybrid or any other speciality fits, our office can not fit you for these types of hard contact lenses. You can continue with a routine exam without a contact lens fitting, or you may notify us to cancel your appointment.

  • How often do you discard your contact lenses?*

  • Do you sleep overnight in your contact lenses?*
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  • Any problems with contact lenses?*
  • Medical Eye Symptoms (Depending on the severity, the appointment may be converted to a Problem Focused Medical Office Visit, and your Wellness Exam must be rescheduled)*

  • You selected: NEW FLASHES OF LIGHTS.

    You may require a medical office visit instead of a routine eye exam.

    If you are experiencing new flashes of lights, new floaters, or part of your vision is missing (like a web or curtain/veil is blocking your view), please contact our office (or any eye care provider) as soon as possible.

    These symptoms can be a sign of a serious eye condition and may require immediate assistance.

     

  • NOTE: If your symptoms make it difficult to check your glasses and/or contact lens prescriptions, we must evaluate/treat the symptoms first as a medical office visit. Then, we will re-schedule your routine exam to check your prescriptions.

     

  • Do you have any medical conditions?*
  • General

  • Genitourinary

  • Gastrointestinal

  • Psychiatric

  • Endocrine

  • Ear / Nose / Throat

  • Allergic / Immune

  • Integumentary

  • Cardiovascular

  • Muscular / Skeleton

  • Respiratory

  • Hematologic / Lymph

  • Neurological

  • Pregnant / Nursing*
  • Do you take any medications?*
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  • Do you have any allergies?*
  • Tobacco / Alcohol usage*
  • Family eye history*

  • OPTOMAP RETINAL EXAM

  • Our doctors highly recommend the ​Opto​map Retinal Screening for all of their patients, of any age and each year, for the following reasons:

    • it is a ​non-invasive technique​ to examine the health of your eye, without the side effects of drops or blurry vision
    • it provides a​ high resolution picture​, that can be compared with future scans
    • it contributes to our standard of care and improves patient education and satisfaction. 

    There is a nominal fee of $30 for this test.

    I have read this and understand that a wide field view of the retina is an important part of an eye exam.

  • Please choose an option*

  • OFFICE POLICIES AND NOTICE OF PRIVACY POLICIES

    • Prescription re-checks: If you have problems with your glasses, we provide complimentary re-checks within 3 months of your exam date. Keep in mind, if no changes are found, a $40 troubleshooting fee will be charged.
    • Contact Lens evaluations:  include sample diagnostic lenses and up to 3 follow-up visits within 2 months (as needed). Problems beyond 3 months incur additional exam fees, beyond 6 months require a new exam. New wearers require a training course. 
    • Electronic communications: you allow us to email/SMS appointment reminders, electronic copies of prescriptions, invoices, receipts, etc. We do not share your data.
    • Payment: is due at the conclusion of the exam. I understand that information obtained from my vision plan and/or medical insurance on my behalf, is not a guarantee of payment or benefits, and that I am obligated to pay any portion of office fees not covered by my insurance company.
    • Advanced Beneficiary Notice of Non-Coverage: Medicare and some insurances may not cover services such as Optos retinal screening photos, contact lens evaluations, or refractions. These fees are listed on our website and reviewed with patients. If you receive these services, you agree that we can not bill your insurance for them and you accept responsibility for the fees.

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  • The listed individuals are authorized to receive my protected health information (such as my prescriptions). I am aware that I can revoke the authorization at any time, but must do so in writing.*

  • By pressing submit, I acknowledge I have read the entirety of this form, am aware and agree to the office policies of SODO Vision Care, and have reviewed their HIPAA privacy policies available at https://www.sodovisioncare.com/readme

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