Do you currently, or have you ever, had any of the following conditions?Please check all that apply.
DILATION CONSENT FORM
A DILATED FUNDUS EXAM IS RECOMMENDED ROUTINELY AT THE TIME OF YOUR INITIAL EXAM FOR BASELINE RECORDING AND USUALLY EVERY OTHER FULL EYE EXAM THEREAFTER (ABOUT EVERY 2-3 YEARS). DILATION ALLOWS THE DOCTOR A BETTER VIEW OF THE PERIPHERAL RETINA FOR DISEASE. IT SHOULD BE DONE ANNUALLY IF YOU HAVE ANY OF THE CONDITIONS LISTED BELOW:
IF YOU HAVE A HISTORY OF HIGH BLOOD PRESSURE, DIABETES, PAST RETINAL PROBLEMS (I.E., RETINAL DETACHMENTS/TEARS), EXTREME NEARSIGHTEDNESS. IT IS ALSO RECOMMENDED IF YOU HAVE EXPERIENCED SUDDEN CLOUDINESS OF VISION, ESPECIALLY IN ONE EYE, "CURTAIN OR VEIL-LIKE" OBSTRUCTION OF VISION, A SUDDEN ONSET OF MANY "FLOATERS" OR FLASHES OF LIGHT OFF TO THE SIDE OF YOUR VISION.
PATIENT CONSENT FORM
PLEASE READ CAREFULLY:I understand that my medical records are confidential. I understand that by signing this consent form I am allowing the release of any information necessary to process my claims for medical or other insurance benefits.I understand that it is my responsibility to pay Killeen Vision Source for the services and supplies provided regardless of any deductible, co-payments, or other variations in my individual insurance program. These are my rights and benefits under my insurance policy.I understand that if for any payments for provided services and/or products is denied to Killeen Vision Source by my insurance, I will receive a bill in the mail and I am responsible for paying for these services or products furnished to me by this provider.I understand that writing a check with insufficient funds is check fraud, and that all check fraud will be referred to the Bell County Attorney's office for collection. A $40.00 returned check fee will be assessed to me.I give my permission to the Killeen Vision Source to release my information for the purpose of billing my claim to my carrier. Any information about my insurance or health is to be held in strict confidence for the sole purpose as noted.
Medicare/Medicaid:If I have Medicare or Medicaid, the Killeen Vision Source agrees to accept assignment, and I authorize the Killeen Vision Source to bill my insurance carrier (providing any and all necessary information and documentation) for whatever benefits I am entitled.
Federal Law requires that we notify you when services to be provided may not be covered by them because it may not meet their guidelines. Vision exams are only covered if you have or found to have a medical condition requiring eye care. This document serves as notice that Medicare denies payment for this service; you will be responsible for payment.
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
I understand that the full Notice of Privacy Practices of Killeen Vision Source, contains a more complete description of the uses and disclosures of my health information and is available upon request. The law requires that Killeen Vision Source make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that:
By signing below I have read the above Patient Consent Form and Notice of Privacy Practices Acknowledgement, I do hereby acknowledge that I am familiar and fully understand the terms and conditions
YOUR KILLEEN VISION SOURCE IS PROUD TO OFFER OUR PATIENTS THE NEWEST TECHNOLOGY.
OCT EYE WELLNESS SCREENING TEST
THE OCT IS AN ADVANCED EYE SCAN THAT USES LIGHT WAVES TO SEE BENEATH THE SURFACE OF THE EYE. IT ALLOWS US TO SIMULTANEOUSLY TAKE A DIGITAL PHOTOGRAPH AND A 3D CROSS SECTION OF THE BACK OF YOUR EYE. THE SCAN IS NON-INVASIVE, PAINLESS AND CAN BE COMPLETED IN 60 SECONDS OR LESS.
THE OCT SCANS LAYERS OF THE RETINA THAT ARE INVISIBLE TO HELP DETECT THESE DISEASES:
THE HEALTH OF YOUR EYES MATTERS TO YOU AND IT MATTERS TO US, TOO. THAT IS WHY WE ARE OFFERING THIS TESTS.
THE FEE FOR OUR WELLNESS SCREENING TEST IS $39.00. IF YOU WOULD LIKE TO ACCEPT THIS TEST, PLEASE SIGN BELOW.