CVG Welcome Form

Chili Vision Group

Experience you want........Quality you deserve
The mission of Chili Vision Group is to provide our patients with personalized, quality eye health services and materials which will contribute to a lifetime of healthy vision. For the past 50 years, we have made each and every patient's visual and wellness needs our first priority. The information and questions below will remain confidential, and are critical to the evaluation of your vision and health. Therefore, it is very important that every question be answered accurately and with details where indicated. Thank you and we look forward to seeing you at your appointment.
Let's Get Started

Please provide your demographic information
Patient's Full Name

First Name Middle Name Last Name Suffix
Sex
Birth Date

Month Day Year
Name of Parent or Guardian accompanying dependent to appointment

First Name Last Name
Address

Street Address

Street Address Line 2

City State

Zip Code
E-mail Address
example@example.com
HIPAA Email Consent
- Patient information (PHI) stored on our computers is encrypted.
- Most popular email services do not utilize encrypted email.
- When we send you an email, or you send us an email, the information that is sent is NOT encrypted. This means a third party may be able to access the information and read it since it is transmitted over the internet. In addition, once the email is received by you, someone may be able to access your email account and read it.
- I understand the risks of unencrypted/unsecure email and do hereby give permission to Chili Vision Group to send me personal health information via unencrypted email. This method of communication is non encrypted and therefore not considered secure, and does not meet the security requirements set forth by the Health Insurance Portability and Accountability Act (HIPAA). I release Chili Vision Group from any and all liability that may arise from the use of non-secure communication.
HIPAA Email Consent

Allow unencrypted email -I understand the risks and give permission to Chili Vision Group to send me personal health information via unencrypted email. DO NOT Allow unencrypted email
Landline Phone

Area Code Phone Number
Mobile Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Do you need an interpreter?
EMPLOYER/SCHOOL
OCCUPATION/GRADE
LOCATION OF LAST EYE EXAM
Doctor or Office Name
DATE OF LAST EYE EXAM

INSURANCE
MEDICAL INSURANCE COMPANY
MEDICAL INSURANCE PLAN NAME
POLICY HOLDER NAME
RELATIONSHIP TO POLICY HOLDER
SUBSCRIBER ID/POLICY #
POLICY HOLDER DATE OF BIRTH

Month Day Year
VISION INSURANCE
POLICY # (IF KNOWN OR APPLICABLE)
POLICY HOLDER NAME
If different than Medical Insurance
POLICY HOLDER DATE OF BIRTH
If different than Medical Insurance
Please take a photo of the FRONT of your insurance card
Please take a photo of the BACK of your insurance card
NAME/ADDRESS/FAX # FOR PRIMARY CARE PHYSICIAN or REFERRING PROVIDER
WHO SHOULD WE SEND REPORTS TO? Name/Fax#

Elective Ocular Wellness Exam

We are now offering advanced technologies to detect early signs of ocular disease
ADDITIONAL ELECTIVE SERVICES

RECOMMENDED BY DR.BROWN

Digital Retinal Imaging: The Zeiss Visucam fundus photo is a quick painless test that provides the doctor with a color picture of the back of the eye. This helps the doctor with timely diagnosis of many conditions such as diabetes, hypertension, macular degeneration, or glaucoma, and provides a lasting, accurate record of your ocular health. It is stored in your permanent record and is an excellent diagnostic tool.

Ocular Wellness Exam: The Optovue OCT is a non-invasive test that looks beneath the retina to help detect vision threatening disease in the early stages. These layers are not visible upon any eye exam or with color pictures. Many ocular diseases will not have outward signs or symptoms, so early detection and prevention is key.
Retinal Imaging

YES. I understand the importance of retinal imaging. Please perform BOTH the Ocular Wellness Exam by OPTOVUE and the ZEISS VISUCAM retinal imaging as elective add-on procedures to my routine examination for the additional fee of $25.00. Not sure: I am interested but would like more information before deciding to proceed.

Elective Dark Adaptation Testing

We are now offering advanced technologies to detect early signs of ocular disease
RECOMMENDED BY DR.BROWN

Dark Adaptation Testing: Age-related macular degeneration (AMD) is the leading cause of adult vision loss in the United States. Fortunately, being testing with AdaptDx Pro can help lower the risk of losing vision by detecting AMD at least 3 years earlier.

One of the earliest symptoms of AMD is poor or failing night vision. In addition, there are several risk factors that may increase your risk of AMD progression:

• Age 40+
• Family history of AMD
• Current or former smoker
• Being overweight
• Caucasian race
• Heart disease, high blood pressure, and/or high cholesterol

If you are experiencing difficulty with seeing or driving at night, or difficulty reading in dim lighting, or have one or more of the risk factors above, screening with this device is advised.

It is a simple, non-invasive, quick test which provides a straightforward objective score to help your doctor know if you have or are at risk for AMD, so measures can be implemented to prevent vision loss.
AdaptDx Dark Adaptation Testing

YES, I would like to be evaluated for Macular Degeneration with the AdaptDx Not sure: I am interested but would like more information before deciding to proceed.

Contact Lens Wearers Agreement

Keeping your eyes healthy and vision sharp
The Doctors and Staff at Chili Vision Group want to be sure your contact lens wearing experience is safe and comfortable. A contact lens is a medical device which comes into contact with the sensitive tissues of your eye; therefore, it must fit properly to maintain the health of your eyes. A contact lens prescription can only be determined by the careful observation of the lens on the eye and the eye’s response to the lens.

THE COMPREHENSIVE EYE EXAM

·Before a patient can be fit with contact lenses, a complete medical and refractive eye examination is necessary.

·This exam is critical to assure the good health of your eyes and to rule out the possibility of any unsuspected or underlying condition that may prevent contact lens use.

ANNUAL CONTACT LENS EXAM

New York State and Federal Law states that a contact lens prescription is valid for only one year.

·All patients are required to have an annual contact lens exam to ensure the contact lenses are fitting well and the patient's eyes are healthy before a valid contact lens prescription can be released.

·Current contact lens wearers who are new to our office and do not have a copy of their contact lens prescription or contact lens packaging will be considered a refit.

·Contact lens evaluations are a separate service from your routine spectacle and eye health exam. It has a separate fee and most insurances DO NOT cover it.

Contact Lens Fees: These fees DO NOT include the cost of the contact lenses, the refraction fee and the comprehensive exam fee. Our technician and/or doctor will discuss the specific fees with you at the appointment based on your own personal needs.

Annual Contact Lens Evaluation: This is for established wearers with no change in prescription, design and/or brand. This fee starts at $90

New Fit Evaluation: Includes first set of trial contact lenses, instruction on insertion/removal, safe care, usage and follow-up appointment(s) for 90 days. This fee is determined by the contact lens manufacturer, lens design, prescription and modality of the contact lenses. The New Fit fee ranges from $100-$285.

ReFit Evaluation: Yearly evaluation that results in change in lens design and/or brand. The Refit fee ranges from $90-$285
Contact Lens History and Questionnaire

I do not wear contact lenses and am not interested in them I have never worn contacts, but I am interested in wearing contact lenses I currently wear contact lenses
IF YOU WEAR CONTACT LENSES, WHICH BRAND
WHAT TYPE OF SOLUTIONS DO YOU USE?
HOW OFTEN DO YOU REPLACE YOUR CONTACT LENSES?
DO YOU SLEEP IN YOUR CONTACT LENSES
Contact Lens Fees

I have read and understand this CONTACT LENS POLICY and would like my contact lenses to be evaluated today and receive an updated RX. This fee starts at $90 I decline having my contact lenses evaluated today. I understand that I WILL NOT RECEIVE an updated contact lens prescription and will not be able to order contact lenses.

Financial/Insurance Policy

This is a required page. Please sign for consent
1. Payment for professional services are due the day the services are provided.

2. Payment for eyeglasses and/or contact lenses is due before the materials are ordered. For your convenience, we accept cash, checks, debit cards and all major credit cards.

3. We are providers on many insurance plans and will happily file those claims on your behalf. Payments for co-pays, deductibles and items known not to be covered by your insurance is expected at the time of your visit. You are also ultimately responsible for all charges for which your insurance company denies payment when we receive your Explanation of Benefits statement from them. We ask patients with insurance for which we are not providers to make payment in full when services are rendered If applicable, an itemized statement will be given to you at the time of your visit so you can submit it to your insurance company.

4. Both Established and New Contact Lens Wearers are subject to an Evaluation/Fitting Fee. This fee varies by the complexity of the individual's prescription and is separate from the exam co-pays. This is a global fee that covers multiple visits until the prescription is finalized and is due at each annual eye exam. These fees are due at the date of the service.

5. For those with Flex Spending Accounts, payment in full for services rendered and materials ordered is expected. An itemized statement that can be submitted to your insurance company for reimbursement will be given to you at the time of your visit.

6. If payment from your insurance company has not been received in 60 days, you will be responsible for paying your account balance in full.

7. Finance charge of $10 will be applied to accounts after 60 days.

8. In some families there is an arrangement between parents as to who is the responsible party. This is strictly between the parents and we require that the parent who requests evaluation and treatment for the child and attends the appointment is the one who will incur the fees.

9. A service charge of $30 will be applicable for all checks returned for any reason.

10. If legal action is required to collect any unpaid charges, you will be billed the cost of attorney fees, court costs and collection fees in addition to any unpaid balances.

11. All purchases of materials are final and non-refundable. Every effort will be made to ensure you are delighted with your purchases.

I acknowledge that I am responsible to pay for all charges associated with the services and materials provided by Chili Vision Group.

I understand that if I fail to make my payments, my account may be turned over to a collection agency. (Please enter name in the box below)
Signature: Please "sign" using mouse pointer or finger/stylus on your touch screen *

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Signature Box: Typing your name below will constitute consent and will be noted in your record *

HIPAA: NOTICE OF PRIVACY PRACTICES

This is a required page. Please check box and sign for consent
HIPAA: I acknowledge that Chili Vision Group has provided the opportunity to read the Notice of Privacy Practices. I have read and and understand this document. I consent to the use and disclosure of my health information for purposed of treatment, payment and healthcare operations. I authorize the same to assignment of benefits from my insurance company. Pursuant to the HIPAA Privacy Rule, in addition to my insurance company I authorize Chili Vision Group to disclose my protected health information to the following person(s) The records authorized to be released include:
Check One

Medical Records Billing Records Medical & Billing Records
List the names of individuals you authorize us to communicate with in addition to the above mentioned entities:
Signature: Please "sign" using mouse pointer or finger/stylus on your touch screen *

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Signature Box: Typing your name below will constitute consent and will be noted in your record *
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Chili Vision Group

Let's Get Started

INSURANCE

Lifestyle Index

Elective Ocular Wellness Exam

Elective Dark Adaptation Testing

Contact Lens Wearers Agreement

Financial/Insurance Policy

HIPAA: NOTICE OF PRIVACY PRACTICES