Patient Comp Eval Forms

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Name (Must match your insurance card)* This field is required.
First Name
Last Name
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Date of Birth* This field is required.
Date
Year
Month
Day
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Email* This field is required.
example@example.com
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Are you a New (never seen or has been 3+ years) or Established Patient?* This field is required.Please select NEW if you have been seen here before but it was more than 3 years ago.
New
Established
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Vision Plans vs. Medical Insurance

Please be advised that most Health Insurance Companies do not cover routine vision services such as an examination for glasses or contact lenses, or to obtain a prescription for either. They typically only cover examinations for MEDICAL purposes, such as conjunctivitis or other eye infections, ocular foreign bodies, cataracts, etc.

While we provide some of these services, it’s important to distinguish between the two types of coverage, in order to ascertain if your benefits can or should be used for your visit.

Several of the large insurance companies offer a stand-alone “Vision Plan” to cover routine vision care for their members.

We are a contracted provider on the following Vision Plans: VSP (Vision Service Plan), EyeMed, and Community Eyecare, (sometimes called BCBS Routine Vision). (Of note: Some VSP plans have other names such as Guardian or MetLife. If you are uncertain if your vision plan is one of these, please speak to your health insurer or your HR department to determine which plan you have.)

If you are requesting an appointment for routine vision services and you do have benefits through a vision plan, you will need to provide the following information to us at the time that you make your appointment, as routine vision benefits must be verified and authorized in advance of your visit.

If you do not provide this information at the time of your booking, we will assume that you are not planning to use a Vision Plan and that you plan to pay out of pocket for your visit. Please be prepared to pay for your services at the time of your visit.

If you need to have an examination for a MEDICAL reason, we will need the following information from you at the time of your booking:
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Do you consent to being billed either as a medical visit or routine vision based on your clinical findings today?* This field is required.
YESNO
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Please select the name of your vision plan:* This field is required.
VSP/Vision Service Plan
Superior Vision
EyeMed
Community Eyecare
Davis Vision
Community Eyecare
None
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Your vision plan is out of network with our office coverage. Do you wish to proceed with today's appointment and pursue reimbursement from your vision plan later? (Cost: $185)* This field is required.Depending on the reason for your exam today, we may be able to bill your medical insurance rather than your Vision plan, even if we are out of network with your vision plan.
YESNO
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Is your Medical Insurance Medicare or another Commercial plan?* This field is required.
Medicare/Medicare Replacement
Commercial Plan
No medical insurance
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Medicare ABN* This field is required.Medicare requires us to have you fill out an ABN for any services that we offer that are not covered. Carefully read your options as it pertains to non-covered services. We offer a number of non-covered services including screening images, screening visual fields, laboratory testing, and dry eye treatments. Our doctor determines medical necessity for each service and will recommend them to you only if she feels they are needed/helpful to your care.
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SEE ABN* This field is required.We offer a number of peer-reviewed, medically necessary services that are not covered by medical insurance plans. An ABN is our way of notifying you of the services in our office that are subject to incurring out of pocket fees. Not all of these procedures will apply to you.
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Consent for Treatment & Use of Records

I, the undersigned, voluntarily consent to treatment by the practitioners and clinical staff of Salisbury Eyecare and Eyewear & Visionary Esthetics. I also voluntarily consent to the use and disclosure of my protected health information (PHI) for treatment, payment and operations and such other purposes that are permitted under the federal Health Insurance Portability and Accountability Act (HIPAA) without a written authorization.

Financial Responsibility
I accept that I am financially responsible for all services rendered on my behalf for which a charge may be associated. I accept personal responsibility for all co-payments, deductibles, and non-covered services, as dictated by my insurance coverage, plus any collection costs for amounts personally owed by me.

In the event that this visit is based on a Worker’s Compensation claim and my Worker’s Compensation claim is not accepted, I agree to have the fees associated with services sent to my private health insurance company.

I acknowledge that not all services provided by Salisbury Eyecare and Eyewear & Visionary Esthetics are covered by my insurance plan for one or more reasons, including but not limited to exclusions from my insurance plan, my insurance plan’s designation of the Salisbury Eyecare and Eyewear & Visionary Esthetics as an out-of-network provider, and/or my failure to provide my insurance card. I acknowledge that some testing services are not billed to insurance carriers, and I agree to be financially responsible for those services.

Authorization (PLEASE COMPLETE):

I authorize payment directly to Salisbury Eyecare and Eyewear & Visionary Esthetics for services for which payments are accepted. I accept responsibility for all charges if I do not have medical or vision insurance. I have been informed that the services provided may not be covered by my insurance plan. I elect to proceed with service with the understanding that I may be personally responsible to pay for the service being rendered to me.

Please Contact our office 24hrs in advance if you are unable to keep an appointment. If you miss your appointment or fail to cancel or reschedule 24hrs in advance, your account will be charged a $50.00 fee.

Please Be on time for your appointment. If you are more than 10 minutes late, we reserve the right to cancel your appointment.
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I authorize person's name * to have access to my complete medical information, including contact lens prescription and ordering, glasses pickup etc. He/She is my husband/wife/mother/father/caregiver * .
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Additional Special Testing at SEE:

Our office offers 2 additional special tests that are NOT covered by insurance and are an additional $50 copay. These 2 tests are:

Digital Retinal Photography:

We highly recommend Digital Retinal Photography for ALL of our patients. This procedure captures a picture and a scan of the inside of your eye including the optic nerve, macula and blood vessels. Digital imaging captures the appearance of these critical structures in your eye and allows Dr. Denton to monitor for changes over time. This procedure aids in the early detection of Diabetes, High Bood Pressure, Glaucoma, Macular Degeneration, Pre-cancerous Lesions, and Retinal Detachments.

Visual Field Screening:

Visual Field Screening is performed to analyze the connection between the eyes and the brain. Therefore, it is able to detect very early changes to the visual system that cannot be seen with photography and dilation alone. It is especially important to have this test performed if you have been having frequent headaches, loss of vision or any family history of glaucoma.

We HIGHLY recommend these tests every year. They give Dr. Denton more information and help her both in finding new diagnoses as well as monitoring how your eyes look so she can detect any changes more quickly.
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Do you consent to the additional special testing?* This field is required.
YESNO
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Do you consent to dilation today?* This field is required.Dilation of the pupil is recommended for every patient, every year. By dilating the pupil, Dr. Denton is able to carefully examine all structures of the eye. After dilation, you may experience blurred vision and light sensitivity for 4-6 hours. If you are NOT dilated, Dr. Denton cannot assess your peripheral retina fully. If you do not consent to dilation today, you attest that you understand you may not hold us liable for exam findings that cannot be seen without dilation.
YESNO
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Do you wear contacts or are you interested in a contact lens fit today?* This field is required.Contact lens fit are an additional copay and are not covered under just a routine eye exam. In a contact lens exam, we evaluate not just the way the contact lenses fit, but your ocular health in relation to contact lenses and your eye's fitness and ability to continue to wear contact lenses. Contact lens evaluations are a requirement EVERY year for a valid contact lens prescription.
YESNO
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Dear Contact Lens Patients:

The standard annual eye examination fee includes all tests that are necessary to evaluate the health status and muscular coordination of the eyes, and to determine a spectacle prescription.

There are additional procedures required to evaluate and manage your contact lens wear. These include:

Visual acuity with your contact lens on the eye

Refraction over your contact lenses to determine if a change in contact lens power would improve vision

Evaluation of the fit of the contact lenses for proper movement, centration and coverage to determine if the contact lens curvature, size, and material are appropriate to continue optimum lens wear.

Detection of abnormal symptoms or eye diseases such as: dry eye syndrome, bacterial/viral infection, corneal hypoxia (insufficient oxygen supply), edema (swelling), neovascularization (abnormal blood vessels), and corneal ulcers (bacterial infection).

Inspection of the inside of the upper and lower lids for contact lens related problems such as: conjunctivitis, styes, scarring, deposits and infections.

Keratometry readings, if needed, to determine if corneal irregularity exists and the best contact curvature for your eyes.

This is the standard of care in our office for contact lens patients to ensure long-term success. Your Contact Lens Evaluation Fee is in addition to the fee for your yearly eye health examination and includes 60 days of follow-up care. This fee varies depending on the level of clinical complexity such as being fit into a new contact lens type, issues with eye health or a change of prescription. Your yearly supply of contact lenses is NOT included in this fee and can be purchased once your contact lens prescription has been finalized by the doctor. Please do not hesitate to discuss with your doctor any further questions regarding your contact lens care.
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Please scan the QR code below to sign up for our contact ordering system Marlo. If you are filling this out on your phone and cannot scan the QR Code please click the link below. Completing this form does not obligate you to order contacts.
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Consent for Electronic Delivery of PrescriptionI would like my eyeglasses and/or contact lens prescription sent to me electronically via my patient portal.
YESNO
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I have received notice of SEE HIPAA practices, Insurance consents, Contact Lens Consent, Dilation and Special testing. I have been provided with electronic copies of my prescription via the patient portal. My signature below verifies my choices on this form and establishes that I have received all consents.* This field is required.I would like my eyeglasses and/or contact lens prescription sent to me electronically via patient portal.
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IF you are a new patient have you completed Online New Patient Paperwork through ? Established patients please skip this last step.* This field is required.New paperwork must be completed if you are brand new to us, or if you haven't seen us in 3 years.
YESNO
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