TENNESSEE VISION THEREPY

The following information will help prepare your child for the upcoming appointment at our office. Your timely completion of these forms will allow us the needed time to process and review your case in advance. We ask that every page be filled out in its entirety and all pertinent medical records including the most recent eye exam are returned to our office at least two business days prior to the scheduled evaluation.

What is a Developmental Vision Evaluation? 
A Developmental Vision Evaluation includes checking the general health of the eye, visual acuity (20/20), refractive condition for appropriate corrective lenses when needed and all of the visual functions required for reading, writing, learning, sports performance and functioning in life. A developmental vision evaluation helps to pinpoint the precise area(s) of concern as well as the depth of the problem and to determine the best treatment options

What tests are performed?
Sensorimotor Testing- measures ocular motility, ocular alignment, and ocular deviation in more than one area of gaze and binocular fusion. It is necessary for detection, assessment, monitoring and guidance for the medical, surgical and optical management of binocular function and motor eye misalignment.

Visual Perceptual Testing- tests the brain’s ability to make sense of what the eyes see. It is important for everyday activities such as dressing, eating, writing, and playing. When a child is behind in the development of visual processing skills, learning can take longer, requiring more cognitive effort that slows down the learning process.

How long does the testing take?
Testing takes approximately 2 hours and is scheduled in the morning before the eyes and brain are tired from a full day of school. We also like to do testing at this time so your child has eaten a good, high protein meal and is most attentive. We try our best to fully engage your child and to make it as fun as possible.

Who can come to the appointment?
Because full attention is needed, it is very important that you do not bring any additional family members such as siblings to the evaluation. We ask only the patient and parents. This minimizes distraction and enhances the productivity of the time spent in our office.

What is my financial policy?
Third parties, such as medical insurance, Medicare and TennCare, severely limit treatment, care options, and the time the Doctor and team can spend with you. Therefore, The Center for Vision Development and Performance Vision Therapy are a fee-for-service facility and payment is due in full at the time of service. The total cost of the Initial Visit is $275, which includes the evaluation, testing, consultation, and a follow-up summary of the Doctor’s findings.

Will I get the results the same day?
Yes! During your consultation all of the findings will be explained to you and literature will be provided. The recommendations from the Doctor, how to proceed and expectations will also be explained.

We look forward to meeting you and your child!

Release of information:

It is often beneficial for us to discuss examination results and to exchange information with other professionals involved in your child’s care. Please sign below to authorize this exchange of information.

I agree to permit information from, or copies of, my child’s examination records to be forwarded to myself or my child’s other health care providers upon their written request or upon recommendation of Tennessee Vision Therapy when it is necessary for the treatment of my child’s visual condition. I authorize Tennessee Vision Therapy, and their staff to exchange information with other professionals involved in my child’s care by means of my signature below. This authorization shall be considered valid throughout the duration of treatment.

Patient Photo and Video Release Form

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my health information.

This release is strictly designed to give permission to Tennessee Vision Therapy, to use my digital patient photos and/or video for their website, social media, and in office presentation for both educational and promotional purposes. Our providers and staff will have permission to use these photos in the manner discussed with me, unless I request the office no longer use them. I understand that by allowing Tennessee Vision Therapy to use my photos, I am expressing consent to share images publicly to educate and explain procedures and results of therapy. I understand that I have the option to decline this request and am not obligated in any way to
provide permission to use these photos.

Office Policy

We schedule our appointments so that each patient receives the right amount of time to be seen
by our physician and staff. That’s why it is very important that you keep your scheduled appointment with us and arrive on time with your new patient paperwork completed. As a courtesy, and to help patients remember their scheduled appointments, we send a confirmation email after scheduling and a reminder call a few days prior to your appointment. If your schedule
changes and you cannot keep your appointment, please contact us so we may reschedule you,
and accommodate those patients who are waiting for an appointment. As a courtesy to our office
as well as to those patients who are waiting to schedule with the physician, please give us at
least 24 hours’ notice.