Retinal eye exam is a part of thorough eye examination. It is recommended yearly. It allows our doctors to evaluate your macula, optic disc, blood vessels, and retina thoroughly to detect eye diseases and conditions at their earliest stages. We can either dilate your eyes or you can pick a retinal/macular imaging option or you can pick both option1 and option2. We do not recommend you to pick option3.
OPTION 1 - Retinal Imaging- Fee: $40- Vision will not be affected- There is no wait time- The doctor will show you the images
OPTION 2 - Dilation Eye Drops- Fee: $0- Vision will be blurry & you will be light sensitive for a few hours- It takes 10-20 minutes to dilate your eyes
OPTION 3 - Opt Out- Declined both retinal Imaging and dilation eye drops- NOT recommended- This will not allow the doctor to perform a thorough eye exam
ELITE VISIONNOTICE OF PRIVACY PRACTICES
This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please read it carefully. The privacy of your health information is important to us.Our Legal Duty: We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties and your rights concerning your health information. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We will use and communicate your health information only for the purpose of providing your treatment, obtaining payments and conducting health care operations.
USES AND DISCLOSURES OF HEALTHCARE INFORMATIONTO PROVIDE TREATMENT: We will use and disclose your health information within ouroffice to provide you with the best health care possible. This may include business office staff, assistants, opticians, physician assistants, nurses, and physicians. In addition, we may share our health information with referring physicians, laboratories, pharmacies, and other health care personnel providing you treatment, including contact lens and frame companies.TO OBTAIN PAYMENT: We may use and disclose your health information to obtain payment for services, materials, and treatment you received in our office. We may do this with insurance forms filed for you by mail or send electronically.HEALTHCARE OPERATION: Your health information may be used during performanceevaluation of our staff, training programs for students, interns, associates, and business and/or clinical employees. It is also possible that health information will be disclosed during audits by insurance companies or government appointed agencies as part of their quality assurance and compliance reviews. Your health information may be reviewed during the routine process of certification, licensing or credentialing activities.APPOINTMENT REMINDERS: Because we believe regular care is very important to your general health, we will remind you of a scheduled appointment or that it is time to contact us for an appointment. Additionally, we may contact you for follow up on your care and inform you of treatment options or services that may interest you or a family member. These may include postcards, folding cards, letters, telephone, voice mail, text or email.ABUSE OR NEGLECT: We may disclose your health information to appropriate authorities if we believe a patient is a victim of abuse, neglect or domestic violence, or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.PUBLIC HEALTH AND NATIONAL SECURITY: We may disclose to Federal Officials ormilitary authorities your health information required for lawful intelligence, counterintelligence, and other national security activities.LAW ENFORCEMENT: As permitted or required by State or Federal Law, we may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime.FAMILY, FRIENDS, AND CAREGIVERS: We may disclose your health information to afamily member, friends, caregiver, or other person who you tell us will be helping you with your home hygiene, treatment, medications, or payment. In case of an emergency, where you are unable to tell us what you want we will use our very professional judgment when sharing your health information. We will also use professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, materials, or other similar forms of health information.TO CORONERS, FUNERAL DIRECTORS, AND MEDICAL EXAMINERS: We may berequired by law to provide information about your health to coroners, funeral directors, and medical examiners for the purpose of determining a cause of death and preparing for a funeral.REQUIRED BY LAW: We may use or disclose your health information when required to do so by law.YOUR AUTHORIZATION: Other than stated above or where Federal, State or Local Law requires us, we will not disclose your health information without your written authorization.You may revoke your authorization in writing at any time. Your revocation will not affect any use of disclosures permitted by your authorization while it was in effect.
ACCESS: You have the right to look or get copies of your health information, with limited exceptions (you must make a request in writing to obtain access to your health information). If you request copies, we will charge you a fee for each page, and per hour for staff time to locate, duplicate and assemble your copy, and postage if you request the copies to be mailed to you.DOCUMENTATION OF HEALTH INFORMATION: You have the right to ask us for adescription of how and where your health information was used by our office for any reason other than for treatment, payment or health care operations and certain other activities. Please let us know in writing the time period for which you are interested. Your request must be limited to no more than six years at a time. We may charge you a reasonable fee for your request.ALTERNATIVE COMMUNICATIONS: You have the right to request that we communicate with you about your health information by alternative means or to alternative location. (You must make your request in writing). Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location. We will make every effort to honor your reasonable request for confidential communications.AMENDMENTS: You have the right to ask us to amend your health information. In order to standardize our process, please submit your request in writing and describe the reason for the change. Your request may be denied under certain circumstances.Request a Paper Copy of this Notice: You have the right to obtain a copy of this Notice of Privacy Practices from our office at any time.COMPLAINTS: If you think that we have not properly respected the Privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office of Civil Rights. We support your right to the privacy of your health information. If you want more information, please contact our office.
ELITE VISIONFINANCIAL & INSURANCE POLICIES
1. All fees for professional services are due in full the day services are rendered.2. Professional fees and/or contact lens evaluation fees are not refundable.3. Emergency medical visits are to be paid in full the day services are rendered. Our office will be happy to file your medical insurance. However, you will be responsible for all fees if your insurance companydecides not to pay for your visit for any reason.4. Fees for eyewear/contact lenses are as follows:- For those patients with vision insurance: all co-pays are due in full. Overages are due in full prior to ordering the eyewear/contact lenses.- Patients with no vision insurance must pay the entire professional evaluation fee prior to evaluation contacts.- All material fees are due in full prior to ordering the eyewear/contact lenses.5. Credits:- There are no refunds on eyewear/contact lenses.- Glasses and contacts orders cannot be cancelled or modified after your insurance is submitted and/or the lab has started creating your orders. Your glasses or contact lenses are considered as medical devices. They can’t be reused for others once they are prepared.- Credits can only be issued during the first 30 days after dispensing of the eyewear/contact lenses. The eyewear/contacts lenses must be returned undamaged. Boxes of disposable contacts must bereturned unopened and undamaged.- Credits can be used for any individual and never expire.6. Warranty:- Eyewear: It is a one-time warranty in one year for your frame and/or lenses due to breakage, including scratches. The frame/lenses will be substituted with the exact same prescription, style, and color. Gross negligence or loss is not covered under this warranty. Glued frames are not covered under this warranty. This warranty cannot be transferred to a different patient/frame/lenses. There is no fee if this happens within the first 30 days. If the frame warranty is used after 30 days, then you must pay a $50 fee or 5% of the original frame retail price (whichever is greater). If the lenses warranty is used after 30 days, then you must pay a $50 fee or 5% of the original lenses retail price (whichever is greater). All parts of the broken frames/lenses must be returned to the office.- Contact Lenses: we offer a 30-day warranty on all evaluation types. Multiple visits might be necessary to provide good comfort and vision. A new professional evaluation fee will be applied if you decide to come back with any contact lens problem after 30 days from the initial evaluation date.7. Other:- All orders for your eyewear/contact lenses must be picked up within 30 days of notification. Failure to do so will result in the forfeiture of your payment and your eyewear/contact lenses will be donated to charity.- In the event you are not happy with the frame you chose, we are more than happy to re-frame you with a new frame. There will be a restocking fee of $100 or 10% of the original complete pair (frame + lenses) retail price. This can only be done within 30 days after dispensing of your eyewear. If the new frame costs more than the old frame, you are responsible for the difference. Exception: on rimless glasses, all sales are final.- In the event you want to add other add-ons (such as anti-glare, transition, etc.) to your lenses after the purchase, you are responsible for paying for entirely new lenses.
OUR INSURANCE POLICIES ARE AS FOLLOWS (IF YOU HAVE INSURANCE):
Elite Vision wants to make sure your insurance carrier pays for your eye exam; therefore, we must file your exam to the appropriate insurance. The main reason of your visit will determine which type of insurance our office will file. It is important for you to understand the two different types of eye examinations/insurance: VISION vs. MEDICAL. Elite Vision does not make up these rules.
Your MEDICAL INSURANCE (and its copay/deductible will apply) will be filed when:• The reason for your visit is either itchy eyes, dry eye, red eyes, pink eyes, or teary eyes AND treatmentis initiated• You come to our office due to a foreign body in the eye• You want a cataracts evaluation/treatment• You want a glaucoma evaluation/treatment• You or your family doctor wants a diabetic eye examination• You have macula degeneration• You have a lazy eye or amblyopia• There is an eye condition prevents you from seeing well even with glasses/contacts
Your VISION INSURANCE (and its copay will apply) will be filed when:• You only want an exam for a glasses/contacts prescription• Blurred vision at distance and/or near is purely due to the need of wearing glasses• A yearly wellness or routine eye exam in the absence of any eye disease
1. I certify that I, and/or my dependent(s), have insurance coverage and assign directly to Elite Vision all benefits for services rendered. Elite Vision DOES NOT guarantee that my insurance will pay my claim even if benefits are verified before the appointment. I will be responsible for all the charges if my insurance does not pay for my services.2. I further expressly agree & acknowledge that my signature on this document authorizes Elite Vision to submit claims for services rendered without obtaining my signature on each and every claim to be submitted for the same date of service for myself and/or my dependents, and that I will be bound by this signature as though the undersigned had personally signed the particular claim dated today or in the future until further notice has been expressed in writing.3. Elite Vision may use my health care information and may disclose such information to the insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or benefits payable for related services.
I have read and fully understood the FINANCIAL & INSURANCE POLICIES statement. I will be responsible for all fees if my insurance decides not to cover for the visit, regardless prior authorizations. Also, I understand that if I have any question about my insurance benefits, I am able to speak to an associate who can answer my questions prior to seeing the doctor.