Patient Intake Form

Welcome to our office! At Planet Vision Eyecare we pride ourselves on providing our patients with the best possible care. In order to best serve you please answer the questions below:

Both of our doctors specialize in early detection of diseases and our office is equipped with the latest technology to offer all of our patients an in-depth eye exam.

For only $78 our retinal health scan includes 4 non-invasive OCT and antioxidant scans:

1) OCT imaging is a non-invasive scanning device that takes cross-sectional and 3D images of the retina. This allows the doctor to see the deeper layers of the retina to detect early signs of conditions like glaucoma, macular degeneration and diabetic retinopathy.

2) Antioxidant screening is a fast and painless way to measure your antioxidant levels. Specifically, the scanner measures a powerful group of antioxidants called carotenoids found in abundance in many fruits and vegetables, which we need high levels of to reduce the risk of disease and degeneration especially in the retina.

These advanced technologies improve the detection of early indicators of eye health problems.

I authorize the doctor to release any information including diagnosis, records of treatment or examinations to me or my child during the period of such eye care to 3rd party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the eye doctor or group insurance benefits otherwise payable to me. I understand my insurance may pay less than the actual billed amount for the services. I agree to be responsible for the payment of all services rendered on my behalf or my dependents.

Consent of Treatment: I hereby grant MY authorization and consent for medical treatment and procedures for myself that no guarantee or assurance has been mode as to the results which may be obtained.

CONSENT TO PROVIDE HEALTH CARE SERVICES TO MINOR CHILD:

I grant MY authorization and consent to arrange, schedule, and/or provide health care services, including the administration of topical anesthesia, dilation and prescription of medicinal drugs, to my minor child, as deemed necessary for the health and welfare of said minor child. This authorization is effective from the date of signature.

Medicare and other commercial medical insurances do not pay for all your health costs, including refractions, routine eye care and examinations, eyeglasses, contact lenses and screening tests. These items and services are not part of your insurance benefits and so you will be responsible to pay for them yourself.

As a courtesy to our patients we are happy to file with your insurance company. NOTE: The patient is responsible for any copays and/or deductibles which your insurance requires. Our doctor completes a comprehensive eye examination. The doctor is trained to diagnose and treat most ocular diseases. If your vision exam is deemed routine it will be filed with your vision insurance. If a medical diagnosis is determined by the doctor your exam will no longer be filed with your vision plan but with your medical health insurance, and for this reason we request a copy of your medical card in your chart. I have read and understood when my vision insurance will be billed and when my medical insurance will be billed by Planet Vision Eyecare.

Planet Vision Eyecare respects the privacy of your medical records and we will do all that we can to secure and protect that privacy. I have been presented a copy of the HIPAA Privacy Practice from Planet Vision Eyecare. I have read and understood the content. I know that any time I can request my own copy of the document. Review HIPAA Privacy Practice

I authorize the doctor and staff at Planet Vision Eyecare to disclose information regarding my medical treatment, medical diagnosis and information regarding my financial account with the following designated individuals or organizations (you may revoke this at any time).

Most people have vision insurance and medical insurance. They are very different in terms of the services they cover and it’s important for our patients to understand those differences. Vision coverage (VSP, Spectera, EyeMed, Davis etc) is mainly designed to determine a prescription for glasses and is not equipped to deal with complex medical conditions and/or diagnoses. It does allow for screenings of conditions, but once they are determined, then medical insurance is filed on those services. When a medical condition is present (such as diabetes, cataracts, dry eye, floaters, etc it is necessary to file the visit with your major medical carrier (BCBS, Aetna, UHC, Cigna, etc) and the co-pays for that insurance will apply. Insurance carriers set these rules and our office is required to follow them. In most cases, there is no way to know prior to the examination which type of insurance our office will be able to file for you.

1. If you have ANY problems or complaints that MAY be attributable to a medical condition which requires a more in-depth investigation and additional medical decision making to rule out any underlying eye disease, we will accordingly bill your MEDICAL insurance, NOT your vision plan. These include, but are not limited to:

• New or sudden blurry vision
• Flashes or floaters
• Dry or itchy eyes
• Eyestrain or double vision
• Eye pain or redness
• Headaches
• Loss of vision

2. There are a variety of systemic conditions that can profoundly and permanently affect a patient’s vision that require a more in-depth investigation, which may include additional testing, follow up visits, and reports to your primary care physician. This type of examination is NOT covered under “vision” plans, and we will bill your MEDICAL insurance, NOT your vision plan. These include, but are not limited to:

• Diabetes
• Lupus, Rheumatoid Arthritis or other autoimmune disease
• Hypertension
• Diseases resulting in use of high risk medications like Plaquenil
• Thyroid disease

3. If you have previously been diagnosed by another eye doctor for any eye issues that require medical decision-making, treatment or management, we will bill your MEDICAL insurance, NOT your vision plan. These include, but are not limited to:

• Cataracts
• Keratoconus
• Dry Eye Syndrome
• Macular or retinal disease
• Choroidal Nevus (freckle in the back of the eye)
• Amblyopic/lazy eye
• History of eye surgery
• Glaucoma/previous diagnosis of high eye pressure

We make every effort to be on every major carrier for your convenience and we will file those claims for you. In the event that we do not take your insurance we will provide you with an itemized receipt so that you may file with your carrier for reimbursement. If you have any questions, please let us know.

I understand the paragraph above & authorize Planet Vision Eyecare to file my insurance by the above guidelines.

Dilation is an important part of a comprehensive eye exam and is required if this is your first eye exam or if it has been two years or more since your last dilation. Dilation will make your pupil (the black part in the center of your eye) large so that Dr. Hetel Bhakta/ Dr. Tuyet-Suong Pham can get a better look at the back of the eye to check for any problems that can occur due to the following:

• Systemic diseases, such as Diabetes, High Blood Pressure, Cancer, and other conditions that can affect the eyes without apparent symptoms to the patient.
  
  
• Physical changes in your eyes, such as cataracts, glaucoma, retinal detachment, macular degeneration, and other conditions that can affect your vision. The dilation can make reading up close difficult, make lights seem brighter than usual, and can cause your vision to be blurry. This can last for approximately 3-5 hours for full Dilation or 2-3 hours for Mild Dilation, although it can last longer for some people. Most people will be able to drive once their eyes are dilated, as long as they have sunglasses. (We will provide temporary sunglasses if needed.) However, if you feel uncomfortable driving while your eyes are dilated, or you have never driven with your eyes dilated, it may be best to have a driver, or stay in the waiting area until you feel comfortable. Please note that there is no additional charge for having your eyes dilated. You will have your eyes dilated if:
  
  

• You are new to our office.
• You are diabetic.
• You have glaucoma or have a family history of glaucoma
• You are over the age of 45.
• You are nearsighted (myopia)
• You have been previously diagnosed with a condition in the back of the eye that needs yearly monitoring.

If you do not fit into the above categories, it is still recommended to have your eyes dilated every year.

Contact Lens Prescription

If you are receiving a contact lens exam, sign below to indicate receipt of your contact lens prescription at the completion of your contact lens fitting.