Please be prepared with the following prior to beginning form:

 
1. Reason for appointment

2. Patient information

3. Parent or Responsible Party information

4. Insurance card(s)

For URGENT requests, please call 865.262.8473, option 0, in addition to completing this form.  If you are experiencing a medical emergency, call 911 or report to an Emergency Department.

 

I, {nameOf}, the undersigned, authorize Bright Eye Consultants PC to leave messages with medical information concerning {patientName} on my voicemail at my phone number of record.

In accordance with the Privacy rule of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, I understand:

1. I may revoke this authorization at any time, except to the extent where action has already been taken accordance to the original authorization for disclosure.  My revocation must be in writing, signed by me or on my behalf, revocation will be effective once received by Bright Eye Consultants PC.

2. The information provided under the release may be subject to re-disclosure by the recipient under circumstances no longer protected by HIPAA Privacy Rules.

3. A copy of this authorization may be used with the same effectiveness as the original.

4. If the requestor or receiver is not a health plan or health care provider, the released information may no longer be protected by federal privacy rules and may be shared with others.

5. I may request a copy of this consent after signing.

This Authorization shall supersede any prior written authorization I have made regarding the use, release, and disclosure of my medical information.  I may receive a copy of this form and Bright Eye Consultants PC’s privacy policy upon request.

I, {nameOf}, the undersigned, authorize Bright Eye Consultants PC to release medical information concerning {patientName} any medical provider or institution to which {patientName} may be referred to assist in my care.

I also authorize Bright Eye Consultants PC to receive any information in my chart from any of {patientName}'s medical providers and institutions.

I authorize Bright Eye Consultants PC to electronically transfer and receive information concerning {patientName} in accordance with the above authorizations.

I authorize and assign rights to Bright Eye Consultants PC to collect photographs of {patientName}'s eye conditions, participation, and procedures for publication for educational, promotional, or other purposes.  I understand that my name will NOT be associated with any publication.  I understand that I may refuse the collection of photographs.

Service for refraction (glasses check), is frequently defined by insurers as a non-covered service.  Other services, such as Visual Field, Photography, Sensorimotor Exam (eye alignment check), Extended Retinal Exam, and others may or may not be covered by your insurance.  However, these exams are sometimes necessary for the doctor to make decisions about your health.

You have the right ask about why a service is needed and how much it may cost.  You may refuse a service, but this refusal may limit the doctor’s ability to make informed decisions about your care.

I, {nameOf}, the undersigned, authorized payment of medical benefits to Bright Eye Consultants PC for any services furnished by Bright Eye Consultants PC.  I understand that I am financially responsible for any amount not covered by my insurance.  I also authorize release of my and the patient’s information to my insurance company or their agent concerning healthcare advice, treatment, service, or supplies provided by Bright Eye Consultants PC.  I agree to pay any unpaid balance on my account nor more than 90 days after the date of service.  A finance charge of 2% per month will be charged for past-due balances.  Should collections become necessary, the responsible party agrees to pay and additional 40% for collections agency fees, plus all legal fees of collection, including attorney fees, court costs, and filing fees.

As part of a complete eye evaluation, dilation of the patient's eyes may be indicated.  This can be important for many reasons, such as evaluation of the structures in the back of the eye or to evaluate the need for glasses.

Eye dilation requires the administration of a few eye drops into each eye.  It takes 30 minutes for the drops to fully dilate the eyes.  Expect the eyes to stay dilated for 24 to 48 hours.  It is common to experience mild blurring of the vision and sensitivity to bright lights while the eyes are dilated.

It is important to alert Bright Eye Consultants staff if you or your child have any heart defects, high blood pressure, or history of seizures or epilepsy, before the eyes are dilated.

Please note that a return clinic visit may be necessary for a dilated eye exam, if it cannot be done today.

Additional information about dilating eye drops: CLICK HERE.

By signing below, I verify that I have read, understand, and agree to the above HIPAA Authorization, Medical Release, Photographic Release, Notice of Non-Covered Services, and Dilation Consent.  I understand that I am responsible for payment of all non-covered services.  I certify that I have provided correct patient medical, insurance, and demographic information.  I understand that I will be responsible for any incorrect information given and agree to financial responsibility due to failure to provide correct insurance information.

If signing for a minor, I hereby certify that I am legally authorized to make healthcare decision for the patient. I understand that I may request a copy of this consent.  I acknowledge that a copy of this consent has been made available to me for review prior to signing.

I have read and understand the above release authorization. I have read, understand, and accept the above: