Vision Exam

Patient Information
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First NameLast Name
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Date
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Email*
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Address*

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Your ID or Guardian's ID*

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Insurance Information
Medical Insurance Name
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Medical Insurance Primary's Name
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Retinal Testing

In some cases, the doctor may find it necessary to do a dilated retinal check or document your retina with imaging to further evaluate your condition and symptoms. Please verify with our front desk about your insurance coverage for these tests (our office fees that may apply). Below is more information about the testing that may be performed or recommended:
Pupil Dilation

Your pupil will be enlarged with medicated eye drops (Tropicamide 1%) and the doctor will shine a bright light to look into your eyes. The side effects of dilation include temporary blurry vision and light sensitivity for approximately 3-6+ hours. You will need to wait an extra 15-25 minutes for the eye drops to take effect. Driving may be uncomfortable & sun protection is recommended afterwards.
Digital Imaging

A series of photos will be taken using our Eidon camera and DOES NOT require dilating eye drops, and you will be able to drive afterwards. Documented imaging will allow the doctor to monitor progression of ocular conditions throughout time. Most insurances do not cover retinal imaging, but please verify with our front desk.

Your MEDICAL INSURANCE may be billed due to certain medical diagnoses that the doctor may find which could require subsequent management or treatment. If you are out of network, a medical visit fee may apply. We can provide an itemized receipt for you to submit to your medical insurance for reimbursement if needed. If you would like a referral to a specialist who is in network with your medical insurance, we can provide you with more information.

If you DECLINE both options for today’s visit, please read our liability release: I have been informed about the importance of having a comprehensive retinal eye examination annually in the detection and diagnosis of eye disease. I am declining the recommendation to obtain a comprehensive view of my retinas. By foregoing the dilation or retinal imaging, I do not hold Aperture Vision responsible for any disease or pathology that goes undetected due to the lack of diagnostic information that could have been obtained by these testing procedures.
Office Policy
Office Policy

1.In the event my insurance provider determines that I am not eligible for visual insurance coverage or eligible for a reduced level of coverage, by signing this statement, I hereby agree to be financially responsible for any and all charges incurred by me and not paid by my insurance provider.

2. I understand all fees of services rendered are due at the time of service and are non-refundable.

3. I understand there may be a re-check or re-fit fee if I request a change to my vision prescription after 90 days from the initial exam / date of service.

Medical Release Authorization and Insurance Assignment

All vision insurances must be pre-approved prior to your examination. If we are unable to verify coverage, all charges must be paid in full when services are rendered. If you are not eligible for insurance benefits or are eligible for less than full coverage, you agree to be financially responsible for any unpaid balance. If you discover that you have insurance after services are rendered, it is your responsibility to file your own claim for reimbursement. The doctor’s office will not back the file claims, post authorize, or refund fees. You also acknowledge that certain examinations and exam findings may not fall into the realm of a routine eye exam, and may deem to be medically necessary to file under your medical health insurance or will need to be referred to another office. You also authorize the release of any medical or other information to process insurance claims.

Acknowledgement of of Notice of Privacy Practice

In the process of providing services requested, we will collect, use, and share certain information provided by the patient. You may request a copy of this form at any time.

TREATMENT: We are permitted to use and disclose your medical information to those involved in your treatment, including but not limited to hospital staff, primary care physicians, and specialists.

PAYMENT: We are permitted to use and disclose your medical information to bill and collect payment for services provided to you.

DISCLOSURES WITHOUT PATIENT AUTHORIZATION: There are situations in which we are required by law to disclose or use your medical information without written authorization or opportunity to object. These include but are not limited to: public health activities, abuse/neglect, health oversight, legal proceedings, law enforcement, worker’s compensation, or as otherwise required by law.

RESTRICTIONS: You may request that we restrict or omit how your protected health information is used or disclosed for treatment, payment, or health care operations. We do NOT have to agree to restrictions, but if we do agree, we will comply with your request except under emergency situations.

I have reviewed Aperture Vision’s Notice of Privacy Practices which explains how my medical information will be used and disclosed.
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Patient Information

Insurance Information

Ocular and Medical History

Retinal Testing

Office Policy