2022 Forms

Wellness Images and OCT-A Information

Healthcare has moved to Early Detection
Vision threatening diseases such as glaucoma, macular degeneration, diabetic retinopathy, or changes from high blood pressure or cholesterol often have no outward signs or symptoms, so our practice is using state-of-the-art technology to assess the health of your eyes. Our doctors can detect vision threatening and systemic diseases in their very early stages, when they are most treatable.

Optomap & Wellness OCT: Our wellness images include both the Wellness OCT retinal scan and Optomap. The Wellness OCT allows the doctors to view the layers of the retina below the surface image captured by the Optomap. The doctor wants you to have these tests as part of your annual visit today. The cost is only $60.

Optomap, Wellness OCT, & OCTA-A: If you are suffering from diabetes, high blood pressure, high cholesterol, rheumatological disease, have a family history or diagnosis of age related macular degeneration. The doctor wants you to have these tests as part of your annual visit today. In this bundled package, the OCT A only costs an additional $20, for a total of $80.
Yes, I accept the fee and would like to have:

Optomap & Wellness OCT (routine annual exam)Optomap, Wellness OCT, & OCT-A (annual exam for patients with diabetes, high blood pressure, cholesterol, rheumotological disease, family history or diagnosis of age-related macular degeneration)
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DEMOGRAPHIC INFORMATION UPDATE

May we contact you using phone, text and email? Please provide your current contact information.
Patient Name(s)
Date of Birth
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Format: (000) 000-0000.
Home Phone
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E mail
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Phone Number
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PATIENT FINANCIAL RESPONSIBILITY

We ask that you read and sign below to acknowledge your understanding of our patient financial policies.
Patient Financial Responsibilities:

* The patient (or guardian, if a minor) is ultimately responsible for the payment for treatment and care. Authorization from your insurance is Not a guarantee of payment.

* We will bill your insurance for you. However, the patient is required to provide the most correct and updated information

* Patients are 100% responsible for payments of copays, deductibles, all other services, procedures or treatments not covered and/or excluded by your insurance coverage. This includes refractions, all overages on materials, options, and quantities not covered by insurance.

* Copays are due at time of service.

* Coinsurance, deductibles and non-covered items are due 30 days from receipt of billing.

* Patients may incur, and are responsible for payments of additional charges, if applicable.

These charges may include:

- Returned check fee: $25.00

By my signature below, I hereby authorize assignment of financial benefits to Enhanced Eye Care and any associated healthcare By my entities for services rendered as allowable understand standard third party contracts. I understand that I am financially responsible for charges not covered by this assignment.

Please acknowledge acceptance of this policy by your initials and signing and dating the form below:
Patient Name
Date of Birth

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Date
Payment for services is expected and due at the time of your visit. The patient is required to provide the most correct and up-to-date insurance information. Patients (or guardian, if minor) are responsible for payment of copays, deductibles, and all other procedures of treatment not covered by their insurance plan. This includes all overages on materials options and quantities not covered by your vision insurance. Coinsurance, deductibles and non-covered items are due 30 days from receipt of billing.

Initial
Spectacle/Contact Lens Prescription Release NoticePursuant to the Federal Trade Commission’s ruling 16 CFR Part 315: I understand that the practice will readily supply a copy of my non-expired spectacle or contact lens prescription at my request. To abide by HIPAA guidelines, in the absence of a secure electronic submission portal, I understand that this prescription will be available to me by fax or postal mail, or that I may request to pick up the document at the office (allowing a reasonable time frame for office staff to obtain the doctor’s signature).

Initial
Lifetime Authorization for Insurance Payments We request your signature on file, in the event the office files insurance for you or for any office procedure. I request that payment of authorized carrier of benefits be made either to me or on my behalf to this eye doctor for any services furnished me by this/these doctors. I authorize any holder of medical information about me to be released to the carriers any information needed to determine these benefits or the benefits payable for related services.

Initial
Notice of Privacy Practices Patient Acknowledgement I have had the opportunity to receive this practice’s Notice of Privacy Practices. I understand that the practice may change the terms of its Notice of Privacy Practices and that any changes apply retroactively to information created while the current notice is in effect. I understand I can obtain this practice’s current Notice of Privacy Practices upon request.

Initial
Medicare Does Not Cover the Refraction or Eyewear

As a convenience to our patients, we are a participating provider for Medicare. We will bill Medicare for your visits. You may also be responsible for an annual deductible and any non-covered fees. Each January, Medicare starts with a new deductible that must be met before claims are paid. If we are the first to file a claim for you this year, it is likely you will not have met your deductible and will owe the full allowed amount. Medicare does not pay for refractive services. This is the vision evaluation part of the examination that determines your eyeglass prescription. Medicare will not pay for routine eye exam services.
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Wellness Images and OCT-A Information

PATIENT FINANCIAL RESPONSIBILITY

Please acknowledge acceptance of this policy by your initials and signing and dating the form below:

Medicare Does Not Cover the Refraction or Eyewear

Lifestyle Index

How often do you experience any of these symptoms?

Report the type of SYMPTOMS you experience and when they occur:

Report the FREQUENCY of your symptoms using the rating below:

Report the SEVERITY of your symptoms using the rating list below: