"I request that payment of benefits be made to me or the doctor for any services provided. I also authorize any holder of medical information about me to release to the carrier and its agents any information needed to determine these benefits or the benefits payable for related services."
"I understand that any services not covered by insurance and co-pays are due at time of service."
"I also acknowledge that I will have an opportunity to receive a copy of the Privacy Practices and Policies of this practice."
Personal & Family Medical History
Please note any personal and/or family medical history (parents, grandparents, siblings, children; living or deceased) for the following conditions:
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
Your Medical History
Have you experienced?
POLICY FOR MEDICAL VISITS
Medical visits include examination and treatment for infections, injuries, allergies, headache, eye pain, diabetic eye care and eye disturbances other than comprehensive eye health and vision exams, eyeglasses, and contact lenses.
Medical visits and medical insurance coverage are separate from optical coverage. Medical visits are covered by outpatient medical insurance, the same as visits to a family doctor. These visits are not optical, and should be covered regardless of whether the insurance includes optical coverage, which may allow an eye exam every one or two years.
For example: If you see the doctor for a medical visit, our staff will gladly file a claim with your insurance carrier. if we are considered out-of-network with your plan, payment will be required at the time of service and documenation can be provided for reimbursement.
THE CHARGES ARE ULTIMATELY YOUR RESPONSIBILITY. Please help us get your benefits by providing current and accurate insurance information.
I have read and agree to the terms stated above.
I authorize the release of information including the diagnosis, records, examination rendered to me and financial information. This information may be released to:
This Release of Information will remain in effect until terminated by me in writing.
Ridgefield Vision Center Contact Lens Evaluation Agreement
The charge for evaluating and determining your suitability for contact lens wear is not included in the comprehensive exam fee or refraction fee. A comprehensive eye exam must be performed prior to the contact lens evaluation. Your insurance plan may or may not cover the cost of the contact lens evaluation. The evaluation fee is for professional services and does not include the cost of the contact lenses.
The following products and services are included in the contact lens fitting and evaluation fee:
The evaluation fees are as follows:
If you are new to wearing contact lenses or need a review of how to properly insert and remove them, we will provide one-on-one training. This is to make sure you are comfortable handling, inserting, removing, cleaning and disinfecting your lenses. These fees are in addition to your contact lens evaluation costs and are not billable to your insurance.
Your contact lens prescription will be given after the initial evaluation period is successfully completed (examination and follow-up visits) and after all fees are paid. Fees for professional services, such as examination fees and contact lens evaluation fees, are not refundable.