CONSENT, ASSIGNMENT, RELEASE and FINANCIAL POLICY:

I understand that payment is due at time of service.  We will accept cash, check, and credit card.  Checks are accepted with valid state issued ID only.  I understand and agree that if a check is returned for insufficient funds, the office will only accept cash or credit card payments thereafter, and I will be obligated to pay a returned check fee of $25.

I request that payment of authorized insurance/Medicare benefits be made on my behalf to Falcon Family Eye Care, P.C., for services furnished me. I authorize the release of any medical or other information necessary to process my insurance claim.  I hereby assign my insurance benefits to be paid directly to the physician.  Falcon Family Eye Care will file your insurance claim at no charge however it is the patient’s responsibility to provide us with current insurance information prior to the date services are performed. 

Falcon Family Eye Care does not base treatment plans on what your medical insurance/vision discount plan does or does not cover.  I recognize that it is my responsibility to know and understand my insurance coverage or lack thereof, and that insurance benefits not presented at time of service cannot be billed at a later date. If additional/alternative insurance information is furnished after time of service, further processing of charges will be assessed a $25 finance service fee. 

Falcon Family Eye Care is happy to provide care for both your eye health and your visual system.  We have made efforts to be included on many medical insurance panels, as well as vision discount plans, in order to make this comprehensive care possible.  Recently, the various insurance companies have become much more stringent regarding what they consider to be ‘covered procedures’.  As a consequence, we have had to change OUR insurance billing policies. 

- If the doctor determines that a patient has entered the office for a medical reason, presenting problem, symptom, complaint or with a systemic diagnosis requiring medical monitoring of their eye health (i.e. Diabetes), the care provided is considered medical and will be billed to the patient’s medial insurer and/or patient accordingly. 
- If the doctor determines that the patient has entered the office for a non-medical/routine vision care reason, without a medical problem, symptom, complaint, or systemic diagnosis requiring medical monitoring of their eye health (i.e. Diabetes), the care is considered non-medical/routine and will be billed to the patient’s non-medical/routine vision care (e.g. vision plan) insurer and/or the patient. 

Verification of eligibility and benefits payable by your insurance company does not constitute a guarantee of claim payment. Final determination of benefits payable will be made at the time a claim is processed.  Not all services are covered by insurance.  In the event that your insurance carrier determines a service “not covered”, you will be responsible for the complete charge.  

If any payment from your insurance company becomes 30 days past due, you will be immediately billed for the outstanding balance. 

I understand and agree that I am financially responsible for any non-covered services, copayments, deductibles, and coinsurance; that any unpaid balance may be subject to collection and attorney’s fees, if assigned to a collection agency, and is the responsibility of the guarantor; that professional fees are due upon completion of examination and that these fees are non-refundable.  I consent to any routine procedures, medical treatment or facility services rendered under general and specific instructions from the attending Optometrist.  Falcon Family Eye Care may also disclose all or any part of my information to any health care provider for continued patient care.    I understand that the Signatures provided below are valid for a period of 3 years. 

PRIVACY POLICY:

The Falcon Family Eye Care Notice of Privacy Practices is available for your review.  If you wish to receive a copy to take with you, please let the staff know, and we will provide you with a copy. 

I have been provided an opportunity to read and receive a copy of the Falcon Family Eye Care Privacy Policy.

DILATION POLICY:

It is Dr. Falcon’s policy and the standard of care that all new patients will have your pupils dilated as part of your comprehensive eye health and vision examination.  Returning patients will be dilated at least every other year, or more frequently as determined by the doctor.  Failure to adhere to this policy may result in dismissal from Dr. Falcon’s care.

The purpose of dilation is to evaluate the health of your entire eye.  Drops are used to enlarge the pupil, allowing Dr. Falcon to see 100% of your retina.  Without the drops, we are limited to examining only the central 30-40% of your eye.  The effects of the drops last approximately 4-5 hours and may include sensitivity to bright light and blurred vision, especially at near.  The standard of care is to have your pupils dilated at least every 2 years, or more frequently with certain eye conditions, and yearly for patients over age 65.  If needed, we will provide you with disposable sunglasses. 

Effective October 1, 2012, if the dilation portion of your eye health and vision examination is deferred to a future visit for completion, there will be a $15 fee, payable at the time of the initial visit. 

CONTACT LENS POLICY AND AGREEMENT

Contact lens insertion, wear, and care is a lot like learning to ride a bike.  It will seem difficult at first, but soon becomes second nature.  As this is a skill you will acquire, we have dedicated staff time to properly train you in care and handling.  We have found that the learning process goes much smoother without the distraction of parents, siblings, or even spouse onlookers.  As such, all trainings are completed one-on-one with a staff trainer. It is our policy that family and friends remain in the reception area (or may even leave the premises) during your training class. 

Learning to insert and remove a contact lens can frequently cause ocular surface irritation.  We have found that if the new wearer is unsuccessful in accomplishing this within 30 minutes, further attempts take this from irritation to pain.  We will halt all training at 30 minutes in the interests of your ocular health.  We are, however, happy to have you return for additional scheduled trainings.  It is our policy that we cannot release the diagnostic contact lenses to the wearer until the wearer is able to properly insert and remove the lenses by themselves. 

A contact lens is a medical device that has the potential to cause blindness if not taken care of properly.  A lens also must fit appropriately to maintain the health of your eyes. Your contact lens prescription can only be determined by careful observation of the lens on your eye and your eye's response to the lens on follow up visits. Because follow up care is essential, it is your responsibility to keep all appointments and follow all lens care instructions, including prescribed replacement schedules.  Conscientious care and compliance with recommended follow-up examinations are required to maintain the healthy functioning of your eyes. To ensure your contact lens success, please read and sign the contact lens agreement and policies outlined below.

• I understand that I will be charged a professional Contact Lens Evaluation Fee in addition to the comprehensive eye exam fee.  This fee is charged to cover the time and expertise necessary to successfully determine the best contact lenses for me. 
• This fee covers the following:
  • Assessment of my visual needs and expectations
  • Diagnostic trial contact lenses as determined by the doctor
  • Evaluation and determination of the correct contact lens parameters for my eye health and vision
  • Training in contact lens insertion, removal, care, and cleaning, as needed
  • Contact lens related follow up visits during the 30-day adaptation period, commencing at the dispense of my first trial lens
• I understand that my failure to keep scheduled follow-up visits during the 30-day adaptation period will result in an additional $45 office visit charge if additional care is needed.
• I understand that the evaluation fee is nonrefundable even if I am unable to successfully wear contact lenses.
• I understand that I must carefully evaluate my contact lens comfort and vision during the adaptation period, and let Dr. Falcon know if I have any concerns. 
• I understand that contact lenses are non-returnable if boxes are opened, marred or if it has been longer than 45 days from the date of purchase.
• I understand that my contact lenses are medical devices and must be used and cared for as prescribed.
• I understand that contact lenses have a limited lifespan and that I risk eye irritation, infection, corneal injury, and possibly vision loss if I exceed the wearing schedule prescribed by Dr. Falcon.  I further understand that the lifespan of my contact lens is reduced by not cleaning them properly.
• I understand that sleeping, swimming, or showering in my contact lenses may result in irritation, infection, corneal injury, and possibly vision loss.  I further understand that even though my lenses may be FDA approved to be slept in, I am still at higher risk for these events than someone who does not sleep in their lenses.
• I understand that eyes are living organs and they change with time.  Therefore, my contact lens prescription is only valid for 1 year.  After 1 year, I must have new comprehensive eye exam with a new contact lens evaluation to refill my contacts.
• I understand that if any time, my contact lenses become uncomfortable, or my eyes become red, painful, irritated, or sensitive to light, I should immediately discontinue contact lens wear and call Falcon Family Eye Care as soon as possible.