Ridgefield Vision Center

Where do you work?
Occupation
Who is your primary care physician?
When was your last physical exam?

RecentlyA year agoIt's been a whileOther
When was your last eye exam?

RecentlyA year agoIt's been a whileOther
What is your preferred Pharmacy?
Where is it?

Street Address

Street Address Line 2

City

Zip Code
Who may we thank for referring you?

Are you older than 18 years?*

YesNo
Parent or guardian’s name
Relation
Phone Number

Area CodePhone Number
Do you have MEDICAL insurance?*

YesNo
Medical Insurance Carrier
Group #
Insured ID#
What is your relationship to the insured party? *
Name of parent/spouse*

First NameLast Name
Date of birth of parent/spouse*

MonthDayYear
Date
Do you have VISION insurance?*

YesNo
Vision Insurance Carrier
Group #
Insured ID#
What is your relationship to the insured party?
Name of parent/spouse*

First NameLast Name
Date of birth of parent/spouse*

MonthDayYear
Date
"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."
Signature*

Clear

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.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature of Patient or Guardian*

Clear

HIPAA Authorization of Release of Information
Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
I authorize the release of information including the diagnosis, records, examination rendered to me and financial information. This information may be released to:
Spouse/Significant Other
Child(ren)
Parent
Other
Information is not to be released to anyone.
This Release of Information will remain in effect until terminated by me in writing.
Messages
I would like to be contacted via*

phone callemailtext message
If unable to reach me:

you may leave a detailed messageplease leave a message asking me to return your calldo not leave a message
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

Clear

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:

Professional examination of contact lens fit and power
Contact lens related follow-up care for 90 days
Trial pair of contact lenses (if available)
New contact lens care and trial size solution, or valuable coupon to purchase solution
Manufacturer rebates to purchase contact lenses through Ridgefield Vision (if available)

The evaluation fees are as follows:

Annual Contact Evaluation	Fee	Lens Types
Level 1: Basic	$100	Soft spheres (excluding monovision)
Level 2: Advanced	$130	Soft torics (astigmatism) Soft monovision Soft multifocals
Level 3: Complex	$185	Rigid spheres Rigid multifocals XR torics (advanced astigmatism)
Level 4: Medically Necessary	$600 and up Evaluation and fee to be determined by the doctor at the time of visit	Keratoconus/Post-Surgical

Training:

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.

Training	Fee	Services covered
Training Level 1	$30	Re-training and review
Training Level 2	$50	Full training for a first time wearer

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.

Signature

Clear
Should be Empty:

Ridgefield Vision Center - Patient Forms

HIPAA Authorization of Release of Information