Patient Intake Form

If yes, please specify:

Thank you for providing this information. It will help us understand your eye care history better.

 
ACKNOWLEDGMENT AND WAIVER FORM

I, hereby acknowledge and understand that Cosmic Contact Lenses ("the Company") shall not be responsible for any medical health problems that may arise now or in the future due to noncompliance or negligence on my part. I voluntarily assume all risks associated with the use of contact lenses and understand that:

1. Compliance with Instructions: I will comply with all instructions, guidelines, and recommendations provided by the Company or its authorized representatives regarding the proper usage, cleaning, and maintenance of the contact lenses.

2. Professional Ocular Examination: I acknowledge that prior to using contact lenses, I have received a professional ocular examination from a licensed eye care provider and have obtained a valid prescription for contact lenses.

3. Regular Eye Health Checks: I understand the importance of regular eye health checks and will schedule and attend periodic check-ups with a licensed eye care provider as recommended.

4. Proper Usage: I will only use the contact lenses as prescribed and directed by the licensed eye care provider, and will not share or use lenses that have been prescribed for another person.

5. Hygiene and Safety: I will maintain good hygiene practices such as washing hands before handling contact lenses, using recommended contact lens solutions, and properly storing the lenses to prevent contamination.

6. Reporting Issues: I will promptly report any discomfort, pain, redness, swelling, or adverse reactions related to the use of contact lenses to both the Company and my licensed eye care provider. 

7. Indemnification: I agree to indemnify, defend, and hold harmless Cosmic Contact Lenses, its affiliates, employees, agents, and authorized representatives from any claims, damages, liabilities, costs, and expenses that may arise from my noncompliance or negligence.

By signing below, I recognize that I have read, understood, and agreed to the terms and conditions outlined in this Acknowledgment and Waiver Form. I further acknowledge that this waiver shall be binding upon me, my heirs, representatives, and assigns.

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.

OUR PLEDGE

 
We understand that medical information about you is personal. We are committed to protecting your privacy and will follow all laws regarding the confidentiality of your medical information.

 
Cosmic Contact Lenses, Cosmic Co., Lily Quinn Optix, and SureSight Optical
USES AND DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS

 
We may use and disclose your medical information for treatment, payment, and healthcare operations. For example, we may use your information to provide you with medical services, process payments for those services, or conduct quality assurance activities.

 
SECURITY SAFEGUARDS

 
We maintain appropriate safeguards to ensure the security and confidentiality of your medical information.

 
YOUR RIGHTS

 
You have the right to request restrictions on how your information is used and disclosed, receive confidential communications, inspect and obtain a copy of your medical records, request amendments to your records, and receive an accounting of disclosures.

INSURANCE BENEFITS AUTHORIZATION, ACKNOWLEDGMENT & ASSIGNMENT OF BENEFITS
This Patient Benefits Agreement (“Agreement”) is entered into on:

Date & Patient name: submitted below

by and between:

and

Cosmic Optical
2761 NW Federal Hwy
Stuart, Florida 34994

Cosmic Contact Lenses and Glasses LLC

1. Purpose
This Agreement authorizes Cosmic Optical and Cosmic Contact Lenses and Glasses LLC (collectively, “Provider”) to verify, request, receive, and manage vision insurance benefits on behalf of the Patient for covered eye care services, materials, and related products.

2. Authorization & Assignment of Benefits
The Patient hereby authorizes and assigns benefits to the Provider and expressly permits the Provider to:

Verify eligibility and access vision and/or medical insurance benefits with any applicable insurance carrier or third-party payer.
Submit claims for professional services, eyewear, contact lenses, and materials.
Receive, endorse, and deposit any insurance or third-party payments issued in connection with the Patient’s care.
Apply received insurance payments toward the Patient’s account with Cosmic Contact Lenses and Glasses LLC.
This assignment applies whether payment is issued directly to the Patient or to the Provider.

3. Financial Responsibility
The Patient understands and agrees that:

Insurance verification is not a guarantee of payment.
The Patient is financially responsible for all charges not covered, denied, or partially paid by insurance or third-party payers.
Any deductible, copayment, coinsurance, non-covered service, or balance remaining after insurance processing is the responsibility of the Patient.

4. Term & Revocation
This Agreement remains in effect unless revoked by the Patient in writing. Revocation does not apply retroactively to services rendered or claims submitted prior to receipt of written revocation.

5. Governing Law
This Agreement shall be governed by and construed in accordance with the laws of the State of Florida.

6. Acknowledgment
By signing below, the Patient acknowledges that they have read, understand, and agree to the terms of this Agreement and authorize the Provider to act on their behalf as described above.