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)
Signature*

Clear
Date*

MonthDayYear
Date

DEMOGRAPHIC INFORMATION UPDATE

May we contact you using phone, text and email? Please provide your current contact information.
Patient Name(s)
Date of Birth
Address

Address

Street Address Line 2

CityState

Zip Code
Cell Phone
Home Phone
E mail
example@example.com
Family Doctor
Emergency Contact Name
Phone Number
PATIENT FINANCIAL RESPONSIBILITY FORM

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 Bymy 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.
Patient Name(s)*
Patient/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Wellness Images and OCT-A Information

PATIENT FINANCIAL RESPONSIBILITY FORM

Lifestyle Index

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: