Vision Exam

Patient Information
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Date
Phone Number*
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Gender*

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Address*

Street Address

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Email*
example@example.com
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Insurance Information

(If your insurance plan is the same as last year, leave blank)
Vision Insurance Name
Vision Insurance Member ID
(Provide the last 4 of Primary's SSN # for VSP)
Vision Insurance Primary's Name
Vision Insurance Primary's DOB
Medical Insurance Name
Medical Insurance Member ID
Medical Insurance Primary's Name
Medical Insurance Primary's DOB
Insurance Card Front

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Insurance Card Back

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Retinal Evaluation Option

CHECKING YOUR OCULAR HEALTH IS IMPORTANT TO VISION!

Retinal eye exam is a part of thorough eye examination. It is recommended yearly. It allows our doctors to evaluate your macula, optic disc, blood vessels, and retina thoroughly to detect eye diseases and conditions at their earliest stages. We can either dilate your eyes or you can pick a retinal/macular imaging option.

OPTION 1 - Retinal Imaging (recommended) - Fee: $40 (may be covered by insurance) - Photodocumentation of retinal health to monitor changes over time - Helps to detect ocular disease - The doctor will show you the images	OPTION 2 - Dilation Eye Drops - Fee: $20 (covered by insurance) - Vision will be blurry & you will be light sensitive for a few hours - Exam takes additional 30 minutes
OPTION 3 - Opt Out - Declined both retinal Imaging and dilation eye drops - NOT recommended - This will not allow the doctor to perform a thorough eye exam	NOTE: For your benefits, there are times our doctors might need to dilate your eyes even though you chose Option 1 or Option 3. Our team will notify you before performing anything. Thank you!

Please pick ONE option (look above)*

Option 1: Retinal Imaging (recommended)Option 2: Dilation DropsOption 3: Opt Out

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 Evaluation Option

Office Policy