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You may save or print a copy of our Privacy Notice, for your records. Click NEXT to sign the Consent to Privacy and acknowledge receipt of this notice.
I, Guardian/Patient* , hereby give my consent to Dr. Sanders-Maubach,to use or disclose, for the purpose of carrying out treatment, payment, or health care operations, all information contained in the patient record of: Name of Patient* Date of Birth*
I acknowledge receipt of the Optometrist Notice of Privacy Practices . The Notice of Privacy Practices provides detailed in formation about how the practice may use and disclose my confidential information .
I understand that the Optometrist has reserved the right to change the privacy practices that are described in the Notice. I, also, understand that a copy of any revised Notice will be provided to me upon request.
I understand the consent is valid until it is revoked by me. A written revocation of consent must be sent to the Optometrist's office, at the address listed above. I also understand that I will not be able to revoke this consent in cases where the Optometrist had already relied on it to use or disclose my health information. Guardian/Patient Signature* Relationship to Patient* Date* Please list the name(s) of any person(s) that you authorize Dr. Sanders-Maubach to discuss your personal health information (PHI) with: Authorized Person(s) Please list the name(s) of any person(s) that you authorized to pick up any hardware/products on your behalf: (this does not include your PHI) Authorized Person(s)
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Optical Coherence Tomography (OCT) is a non-invasive scan that uses light waves to take cross-section images of your retina. This screening does not require dilation and allows your doctor to see all nine distinctive layers of your retina.Vision threatening diseases such as glaucoma, macular degeneration and diabetic retinopathy often have no outward signs or symptoms in the early stages. This unique technology can help our doctor detect vision threatening and systemic diseases in their very early stages, when they are most treatable.The screening fee is $30, due when services are rendered. This procedure may be billed to your medical insurance, if medical diagnosis is determined by the doctor. If filed medically, it is no longer a screening and considered Ophthalmic Diagnostic Imaging (Nerve/Retina), in which the amount billed will differ from the screening charge. You may be required to submit a receipt for reimbursement from your insurance provider.Yes Signature: Signature Date: Date No Signature: Signature Date: Date