Welcome! Thank you for choosing The Eye MD for your eye care needs. Please complete the following information and return it as soon as possible.

By providing my contact information above, I authorize my health care provider to employ automated outreach and messaging systems to notify me regarding scheduled appointments, scheduling of appointments, and or balances due.

The Eye MD is committed to providing all of our patients with exceptional care. When a patient cancels an appointment without prior notice, it may prevent another patient from being seen. Kindly provide 24 hour notice to cancel or change a scheduled appointment. We reserve the right to charge a $35 fee for missed appointments when prior notice has not been given.

At The Eye MD, we do our best to assist with insurance verification and eligibility in order to best serve our patients; however, this information is often complex and may require further assistance from you. For further questions, please contact our office at 770-691-5176 or email us at hello@theeyemd.sprucecare.com.

Office visits will be billed to your medical insurance company as a medical exam. This office DOES NOT accept any vision insurance plans.

The Eye MD contracts with most major insurance plans; however, I acknowledge that it is my responsibility to confirm specific health plan coverage and benefit levels. I understand that I am financially responsible and agree to pay any charges for care rendered to me not covered by my insurance plan. I agree that for services rendered to me by The Eye MD, I will pay my account at the time of service or upon insurance claim processing.

If payment plan consideration is necessary, I understand that it is my responsibility to call and make financial agreements satisfactory to The Eye MD for payment. 

Any benefits under any policy of insurance or other party liable to the patient, is hereby assigned to The Eye MD. If copayments and/or deductibles are assigned by my insurance company or health plan, I agree to pay them to The Eye MD.

If you do not have insurance, payment is required at the time of service and you will be seen as a Self Pay patient.

Please be aware that when we call to verify your benefits, your healthcare insurance company discloses to us that verification of benefits is not a guarantee for payment. Payment will be finalized according to your plan's benefits when your healthcare insurance company receives and processes the claim.

Dilating Information: Dilating drops are used to dilate or enlarge the pupils of the eye to allow the ophthalmologist to get a better view of the inside of your eye. Dilating drops frequently blur vision for a length of time which varies from person to person and may make bright lights bothersome. It is not possible for your ophthalmologist to predict how much your vision will be affected. Driving may be difficult immediately after an examination, so it's best if you make transportation arrangements. Adverse rection, such as acute angle closure glaucoma, may be triggered from the dilating drops. This is extremely rare and treatable with immediate medical attention. Please call us immediately if you have symptoms including severe pain, eye redness, light sensitivity, and halos following your dilated exam. I hereby authorize The Eye MD to administer dilating drops.

Refraction Information: Refraction is the test used to determine a glasses prescription. Your ophthalmologist may also use a refraction to ensure blurry vision is correctable in order to further assess medical problems. Refraction is required by some insurance companies as part of some types of examinations such as cataract evaluations. Most medical insurances, such as Medicare, do not cover the cost of a refraction. You may be responsible for the $50 refraction fee at the time of service.

Consent for Treatment: I authorize The Eye MD to assess and treat me, complete tests and administer medications considered necessary or advisable. I understand that my healthcare provider is available to explain the purpose of any procedure and that I have the right to refuse, even if against medical advice.

Release of Medical Information: If I would like a copy of my health information releasedto me or any individual(s), I will request and submit an Authorization for Release of Medical Information. A release may be revoked by me in writing at any time. I understand that a copy of my records is subject to fee for labor/supplies/postage.

Notice of Privacy Practices: I acknowledge that I have been made aware The Eye MD's privacy practice. I understand a copy of the Notice of Privacy Practices is available at myrequest. Patient / Authorized Signatory

I understand that in consideration of the services provided to the patient, I am directly and primarily responsible to pay the amount of all charges incurred for services and procedures rendered at The Eye MD. I am responsible for any applicable deductible or copayment prior to the provision of services. The Eye MD will provide me with an estimate of my total financial responsibility and the date by which this amount must be paid in full. I understand that due to the individual needs of each treatment or procedure, this fee is only an estimate. In the event my care exceeds the amount of the estimate, I will be financially responsible for the balance. I further understand that such payment is not contingent on any insurance, settlement, or judgement payment. The Eye MD may file a claim for payment with my insurance company as a courtesy to me. If the primary insurance company fails to pay The Eye MD in a timely manner for any reason, then I understand that I will be responsible for promptly payment of all amounts owed to The Eye MD. Should the account be referred to a collection agency or attorney for collection, the undersigned shall pay all costs of collection, including a reasonable attorney's fee.

Dr. Day values education and endeavors to teach through lectures, publications, teaching conferences, and media. By signing here, you provide permission for Dr. Day to use de-identified testing or unidentifiable photographs in any medium for educational purposes.

If you provide your Primary Care Physician's name and sign the Authorization to Release and Receive Medical Information, we will attempt to gather the following information from their office and you may skip this section. Please provide any updated information or relevant changes. Please note that if we are unable to collect your medical history and medications from your primary care physician, we will review this information during your appointment.

Release of Protected Health Information: I hereby authorize or release any and all pertinent information regarding my medical care, as needed, to assist in my ongoing treatment to or from third party health care providers, laboratories, radiology facilities, or any other institutions and providers. I also authorize that I have the right to revoke this authorization at (initials) any time by sending a written notification to The Eye MD.

For new patients, established patients who may be having a new problem, or our patients who we haven’t seen for a while, we need to update our records as to your general medical health. In each area, if you are not having any difficulties, please check “No Problems.” If you are experiencing any of the symptoms listed, PLEASE CIRCLE THE ONES THAT APPLY, or explain any that may not be listed. If you have any questions about this, please ask one of the technicians or Dr. Day.