Form

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Patient's Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Area CodePhone Number

Medical Plan Name*

Vision Plan Name*

Name of person responsible for insurance

Date of Birth

Date

Please upload ONE photo of your insurance cards

Browse Files

Contact Lens Patients

There is a separate fee for contact lens evaluation each year. A contact lens evaluation is required each year to write a prescription for contact lenses. This service is not covered by insurance. You will be required to pay at time of service.

Please check one of the following:*

I wear contacts and understand.I am new to contacts and understand.I do not wear contacts so this does not apply to me.

Please check one of the following:*

I wear contacts and understand.I would like to be fit with contacts and understand.I would like to discuss the possibility of contacts and understand.I do not wear contacts and I am not interested in wearing contacts at this time.

Authorization

I request that payment for authorized medical benefits rendered to me be made on my behalf directly to Dr. Pamela Saus, OD.

I understand that my signature requests that payment be made and authorizes release of medical information necessary to pay the claim.

I understand that I am financially responsible for any charges not paid by said insurance. If co-payment and deductibles are designated by my insurance company or health plan, I agree to pay them to Dr. Pamela Saus, OD.

I authorized Dr. Pamela Saus, OD to release any information required to process any and all claims for reimbursement on my behalf. A copy of this authorization may be used in place of the original.

Signature*

Vision vs. Medical Insurance

Many people have vision coverage and medical coverage. They are very different in the terms of the services they cover. Vision coverage (Eyemed, VSP, Davis, etc.) are designed to determine the patient’s eyeglass prescription. It is not meant to deal with medical conditions or diagnoses. It does allow for screenings but once a condition has been determined all care then gets submitted to your medical insurance. When a medical condition (Diabetes, glaucoma, cataracts, floaters, etc.) is present, it is necessary to submit the visit to the major medical insurance (Aetna, Cigna, BCBS, etc.) The copays for that insurance will apply, as well as any deductibles, co-insurances and non-covered fees. These rules are set forth by the insurance companies and our office is obligated to follow.

Signature*

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We have a legal duty to safeguard your protected health information (PHI). We use and disclose health information for many different reasons such as treatment, obtaining payment for treatment, healthcare operations, health oversight activities, workman’s compensation, and appointment reminders.

You have the following rights with your PHI: the right to request limits on uses and discloses of your PHI, the right to choose how we send your PHI to you, the right to see and get copies of your PHI, the right to get a list of the disclosures we have made, and the right to correct and update your PHI.

Persons authorized to receive information

Signature*

OCT Screening (Ocular Ultrasound)

Ocular Coherence Tomography ( OCT ) captures detailed images below the surface or your retina. OCT can assist us in early detection of glaucoma, macular degeneration, diabetes and optic nerve disease. It will also serve as a baseline as we follow your health in subsequent years. The scan is painless and easier than having a picture taken.

We recommend that our patients receive this test as part of their comprehensive eye health exam. The fee for this procedure is $39.00 and not covered by your insurance.

If there is a medical reason for the test, your medical insurance will be billed and a more detailed scan will be performed. In most cases, the doctor will review your results with you on the same day of your test.

Please check one:*

Yes, I want to have an OCT scan done.No, please ask me again next year.

Cancellations require 24 hours notice. I understand that I will be charged $25.00 for all missed appointments. *

In September 2024, a law was passed that requires a signature from the patient when they receive a copy of the glasses/contact lens prescription. In order to comply, we will be handing you your finalized script at the end of the exam and asking that you initial a running list in the office.

Replacement prescriptions, written at later date, will be provided at a fee of $10.

Signature*