Name

First Last

Date

What brings you into the office today?

If there are any changes, please circle yes and provide the updated information

Name Change:

Yes

Previous name:

First Last

Address Change:

Yes

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number Change

Yes

New number

Email Address change:

Yes

New email

Employer or Occupation change:

Yes

Medical Insurance Change

Yes

New plan name:

New id #:

Primary Name:

DOB;

Vision Insurance Change

Yes

New plan name:

New id #:

Primary Name:

DOB:

Change in Primary Care Physician

Yes

Please fill out if whether there is a change or not

Current Medications:

Any change in your health:

Signature

Date

We are proud to introduce the latest in retinal imaging, the Optomap. It is painless, quick and the doctor’s preferred method of monitoring the health of your eye. This instrument will enhance our ability to detect and monitor retinal defects associated with common systemic diseases such as hypertension, diabetes, high cholesterol, and thyroid problems. Through this digital imaging of the retina, we can observe early changes in the eye relating to glaucoma, cataracts, and macular degeneration. Optomap can detect debilitating or potentially fatal disorders that can be present in the retina.

This technology can be used without dilation, and will be a permanent part of your medical records. There are no side effects with this test.

This technology is our preferred way of monitoring the eye over time.

By the time you have symptoms affecting your vision, it is typically too late to prevent permanent sight damage. We care about your vision and want to be sure we actively monitor your eye; the optomap retinal image is the best way to do this.

There is a nominal fee of $29 to perform this procedure. This includes dilation if the doctor deems necessary.

Yes, I would like to have the Optomap done today

No, I would like to have my eyes dilated today. I understand that my near vision will be blurry and I will be light sensitive for 4-6 hours.

I would like to discuss this with Dr Lee

Print Name:

First Last

Date

Patient/Guardian Signature:

Medical vs. Vision insurance explanation

Most people have vision insurance and medical insurance. They are very different in terms of the services they cover and it is important for our patients to understand those differences. Vision coverage (VSP, Spectera, EyeMed, Davis, ect….) is mainly designed to determine a prescription for glasses and is not equipped to deal with complex medical conditions and/or diagnosis. It does allow for screenings of conditions, but once they are determined, then medical insurance is filed on those services. When a medical condition is present (such as diabetes, cataracts, dry eye, floaters, etc.) it is necessary to file the visit with your major medical carrier (BCBS, Aetna, UHC, Cigna, etc.) and the co-pays for that insurance will apply. Insurance carriers set these rules and our office is required to follow them. In most cases, there is no way to know prior to the examination which type of insuran,ce our office will be able to file for you.

1.If you have ANY problems or complaints that MAY be attributable to a medical condition which requires a more in-depth investigation and additional medical decision-making to rule out any underlying eye disease, we will accordingly bill your MEDICAL insurance, NOT you vision plan. These include, but are not limited to:

•New or sudden blurry vision	•Eye pain or redness
•Flashes or floaters	•Headaches
•Dry or itchy eyes	•Loss of vision
•Eyestrain or double vision

2.There are a variety of systemic conditions that can profoundly and permanently affect a patient’s vision that require a more in-depth investigation, which may include additional testing, follow up visits, and reports to your primary care physician. This type of examination is NOT covered under “vision” plans, and we will bill your MEDICAL insurance, NOT your vision plan. These include, but are not limited to:

•Diabetes	•Lupus or autoimmune disease
•Hypertension	•Diseases resulting in use of high risk medications like Placquenil
•Thyroid disease

3.If you have previously been diagnosed by another eye doctor for any eye issues that require medical decision-making, treatment or management, we will bill your MEDICAL insurance, NOT your vision plan. These include, but are not limited to:

•Cataracts	•Macular or retinal disease
•Amblyopic/lazy eye	•History of eye surgery
•Glaucoma/previous diagnosis of high eye pressure

We make every effort to be on every major carrier for your convenience and we will file those claims for you. In the event that we do not take you insurance we will provide you with an itemized receipt so that you may file with your carrier for reimbursement. If you have any question, please let us know.

I understand the document above and authorize Dr. Lee and Accurate Family Vision Pllc. to file my insurance by the above guideline

Signature

Date

We understand that situations may arise in which you will need to cancel or reschedule your appointment. However, each time a patient misses an appointment without providing the proper notice, another patient is prevented from receiving care. Therefore, any patient who fails to arrive for a scheduled appointment without canceling or rescheduling the appointment 24 hours prior to the scheduled appointment time is considered a No Show.

Patients who No Show 3 or more times in a 12 month period will be charged a non-refundable $50 fee. No Show fees are the responsibility of the patient or guardian and must be paid in full before a new appointment will be scheduled.

We appreciate your understanding and cooperation.

Please sign below to acknowledge that you have read and understand the Accurate Family Vision patient No Show policy.

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