EYECARE ASSOCIATES OF VIERA

EYECARE ASSOCIATES OF VIERA
PATIENT INFORMATION SHEET
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First and Last Name*
Birthdate*

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Address

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PAYMENT IS REQUIRED AT TIME OF SERVICE*
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HIPAA Privacy Policy Acknowledgment

Receipt of Privacy Notice

I hereby acknowledge that I am aware of the HIPAA Privacy Notice explaining how my health information will be handled in various situations. - understand that I am able to request a copy of this notice, or discuss any questions I may have regarding the privacy notice with my provider, and am aware that federal law requires that a signed copy of this form be retained with my Personal Health Information file.

Release of Information

I hereby authorize Eyecare Associates of Viera, LLC to release to my insurance company and/or associated professionals any information from my medical record, which may be necessary to determine benefits payable under my policy.

Assignment of Benefits

I authorize Eyecare Associates of Viera, LLC to act as my agent in obtaining payment from my insurance company, and authorize payment of said benefits directly to Eyecare Associates of Viera, LLC. I understand I am financially responsible for any charges not covered by my insurance and/or settled by my claim.

By signing below, I acknowledge receipt of the HIPAA Privacy Policy, and grant permission to release selected medical information for purposes of payment, and assign Eyecare Associates of Viera to act as my agent in obtaining payment from my insurance company.
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Printed Name*
Dilation Consent

Dilation is an important part of a comprehensive eye exam. Dilation will make the pupil (the black part in the center of the eye) large so that Dr. Manguikian can evaluate the back of the eye and check for any problems and/or diseases that can occur.

The dilation will make reading up close difficult, and make lights seem brighter than usual. This will last for 3-5 hours, although it can last longer in some people. Most people will be able to drive once their eyes are dilated, we recommend having sunglasses (which we can provide, should you not have any However, if you feel uncomfortable driving, or have never driven with your eyes dilated, it may be best to have a driver.

I understand the procedure and consent to having my eyes dilated.
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Cancellation Policy

You may cancel or reschedule your appointment up to 24 hours ahead of scheduled time. If you do not make changes at least 24 hours ahead of appointment time, you will be subject to a late cancellation fee of $35.00. All no shows are a $50.00 fee.
I have read and acknowledge the Cancellation Policy.*
Initial
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Credit Card on File Consent

By signing below, I authorize Eyecare Associates of Viera to keep my signature and my credit card information securely on-file in my account. I authorize Eyecare Associates of Viera to charge my credit card for any outstanding balances when due after the processing of my insurance.

*Please bring the credit card you would like to keep on file*
Credit Card Holder's Signature

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Opto Map
We provide our patients with the best possible standard of care.

Retinal images are an essential part of your annual comprehensive eye exam. Because of this, we perform optomap® retinal imaging on our patients:
optomap® : When reviewed, the scan becomes a permanent part of your medical record, enabling the doctor to make an important comparison should potential vision threatening conditions show themselves at a future examination. Retinal problems such as macular degeneration, glaucoma, retinal holes, retinal detachments, diabetic retinopathy and many systemic diseases can now be seen without dilation* for most patients. Our doctors prescribe optomap® retinal imaging for all patients once per year.

* If an optomap® is performed, you may or may not need dilation depending on the results of
the images. However, dilation is highly recommended.

Early detection is crucial!

As part of your pre-test work up, we will capture optomap® images for review with the doctor during your examination today. There is a $39.00 co-pay for this procedure. The service may be covered by your insurance* if being used to actively follow disease.

* Insurance coverage of this procedure will depend on your medical insurance.
I have read and understand this document: *

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Should be Empty:

	Self	Family
Cataracts
Eye Surgery
Glaucoma
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Crossed/Lazy Eye

	Self	Family
Diabetes
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High Blood Pressure
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EYECARE ASSOCIATES OF VIERA

PATIENT INFORMATION SHEET

HEALTH INFORMATION

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Opto Map