Hillcrest Vision - Patient Forms 5-25

Who is responsible for payment?
Phone Number

Area CodePhone Number
Do you have MEDICAL insurance?*

YesNo
Medical Insurance Carrier *
Primary Member Name*

First NameLast Name
Primary Date of Birth*

MonthDayYear
Date
Insured ID# *
Last 4 numbers of primary Social Security*
Do you have VISION insurance?*

YesNo
Vision Insurance Carrier
Primary Member Name*

First NameLast Name
Primary Date of Birth*

MonthDayYear
Date
Insured ID#
Last 4 numbers of primary Social Security*

Medical History
Please list all medications and diagnosis
Allergies
Eye surgeries
List any other medical conditions
Do you wear prescription glasses?*

YesNo
Are you interested in purchasing glasses today?*

YesNoMaybe
Do you wear contacts?*

YesNo
Are you planning on getting a contact lens evaluation today?*

YesNo
What problems or concerns would you like addressed at this visit?

iWellness Imaging Consent
TThe iWellness scan is a fast, painless scan to detect early signs o eye disease such as glaucoma and macular degeneration before symptoms appear in a dilated eye exam. It is highly recommended for all patients 10 years and older. The cost is $55 not covered by insurance. This scan does not replace dilation.
iWellness*

Yes, I want to have the iWellness imaging performed.No, I do not wish to have the iWellness imaging performed.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES:

By my signature below, I hereby acknowledge that I have been offered a copy of the Practice's Notice of Privacy Practices. I understand I may revoke this consent at any time by making a request in writing, except for information already used or disclosed.

By my signature below, I authorize the practice to communicate with me by phone, text, or email, and to leave general messages on my answering machine or by voicemail.
Please list any persons with whom we may discuss your health/account information
CONSENT TO TREATMENT:

By my signature below, I do hereby voluntarily consent to treatrent by optometrist of the practice for an eye exam and to any related diagnostic procedures and treatments as necessary in the judgment of the optometrist. I
acknowledge that eye exams are not always routine in nature, and at the discretion of my optometrist, my medical insurance may be billed accordingly.

INSURANCE BILLING

By my signature below, I understand that Hillcrest Vision OD PA will bill my insurance on my behalf to carriers which they are providers for. I understand that the practice cannot guarantee anything regarding my insurance, as it is a contract between me and the insurance company, not with the office. The office will do its best to provide as much information as possible, but I understand it is my resporisibility to know my insurance and benefits. I understand it is my responsibility to obtain any referrals or prior authorizations as necessary, and I am responsible for any balances owed due to a lack of referral or prior authorization.

FINANCIAL:

By my signature below, I understand that payment for all services is expected at the time of service. I understand that glasses and contact lenses must be paid for in full when products are dispensed. If I cannot do so, I
understand I may not be able to leave the office with the products. By my signature below, I agree to all of the above while I am a patient of the practice.

INTERN:

Hillcrest Vision is proud to be a teaching facility for future optometrists. This means our patients may be scheduled with and examined by a student doctor who is being supervised by an attending optometrist. Any patient examined by an intern will also have their case reviewed by the attending and the chance to ask any questions. By my signature below, I consent to an examination by interns and attending optometrists at Hillcrest Vision.
Name of patient

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Hillcrest Vision - Patient Forms

iWellness Imaging Consent