The mission of Eye Care Associates is to provide a personalized experience, focused on superior eye care, quality products and excellent service. 

Thank you for taking the time to fill out this form prior to your appointment.  This form goes over your current concerns about your eyes and vision, as well as reviewing your health history.  

Note: Existing patients - we do have some of this information as part of your record from previous visits, but we ask that you update it once again as medications, symptoms, etc can change over the course of a year.  Thank you!

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Many people experience a variety of symptoms after working at their computer for some period of time. If you answered yes to any of the questions above, there is a new type of eyewear lens that can eliminate the symptoms and dramatically improve your comfort level when working on a computer. These eyewear lenses result from a new vision testing technology, developed specifically for computer users, which our office has been trained and certified to use. Please make sure to discuss these issues with the doctor.

During a comprehensive eye exam our doctors need to evaluate the overall health of your eye. With the Optomap Retinal Exam, we can screen for retinal complications including macular degeneration, glaucoma, and retinal holes or detachments.

This screening procedure can also detect systemic problems unrelated to the eye that may show signs in the retina such as diabetes, hypertension, cancer/tumors, auto-immune disorders, and others, earlier than possible with traditional methods. It provides a permanent record of your retinal condition, and each subsequent year the images can be viewed side by side to discover subtle changes and monitor your continuing eye health.

The optomap ® Retinal Exam:

• Is as fast as taking a picture.
• DOES NOT REQUIRE DILATING DROPS. You may not need to be dilated today, potentially eliminating a 30-minute wait and avoiding side effects such as blurry vision and light sensitivity.
• Saved in your file enabling our doctors to make important comparisons during your annual eye exam.

There is a $35.00 copay for the optomap ® Retinal Exam.

Privacy Practice Acknowledgement

I have received the Notice of Privacy Practices and have been provided an opportunity to review it.  

Patient Waiver/Billing Policy

Because patients often have both medical and vision insurance, it is important to understand teh differences. Vision insurance does not cover medical eye problems, just as most medical insurances do not cover routine vision problems. 

    Vision Insurance                                                                                                        Covers routine eye examinations only                                                                                Helps pay for glasses or contact lenses 

    Medical Insurance                                                                                                          Covers exams where any medical condition that can affect the eyes is                           evaluated. Examples of these conditions includes but not limited to the following:              Diabetes           High Blood Pressure      Taking high risk medications      Eye Diseases        Cataracts          Infections                      Dry Eye                                       Allergies              Lazy Eye           Crossed Eye                   Glaucoma                                   Abrasion

After your examination, the doctor will determine to which insurance the exam will be filed. Glasses and/or contact lenses might still be filed to your vision insurance if the exam is filed to your medical insurance. We try to be a provider on all major carriers. If we are a provider for your insurance we will file a claim to your primary insurance carrier. However, in the event we are not on your providers panel, we will provide an itemized receipt so you may file the claim for yourself.

If you have a secondary insurance, and the copays or co-insurance is not automatically transferred, you will receive a statement, and you must file the secondary claim. The balance on that statement is your responsibility. Eye Care Associates will do our best to file all necessary insurances, however, there may be instances where it will be your responsibility to file a secondary insurance. 

I understand the information above and authorize Eye Care Associates LLC to file a claim with my insurance

I understand that all serviced I received may not be covered benefits as defined by my health and/or vision insurance policies. I have decided to receive these services. I agree to be financially responsible for all services not covered by my health and/or vision insurance policies. I am aware that payment is required in full at time of service. 

 
All sales are final. No refunds on services. Accounts 30 days past due are charged a 1.5% monthly finance charge. The responsible party shall be liable for all collection costs, including but not limited to attorney fees, and court costs. 

I understand the information the information above and authorize Eye Care Associates to file a claim with my insurance.

Summery of the HIPAA Privacy Rule

HIPAA is a federal law that gives you the rights over your health informtation and sets rules and limits on who can look at and receive your health information.

Your Rights

You have the right to:

• Ask to see and get a copy of your health records.
• Have corrections added to your health information.
• Receive a notice that tells you how your health information may be used and shared. 
• Decide if you want to give your permission before your health information can be used or shared for certain purposes, such as marketing. 
• Get a report on when and why your health information was shared for certain purposes. 
• If you believe your rights are being denied or your health information isn't being protected, you can: 
  • File a complaint with your provider or health insurer, or
  • File a complaint with the U.S. Government

You also have the right to ask your provider or health insurer questions about your rights. You also can learn more about your rights, including how to file a complaint from the Web site at www.hhs.gov/ocr/hipaa/ or by calling 1-866-627-7748.

Who Must Follow this Law?

• Doctors, nurses, pharmacies, hospitals, clinics, nursing homes, and many other healthcare providers. 
• Health Insurance companies, HMOs, most employer group health plans. 
• Certain government programs that pay for healthcare, such as Medicare and Medicaid. 

What Information is Protected?

• Information your doctors, nurses, and other health care providers put in your medical record. 
• Conversations your doctor has had about your care or treatment with nurses and other healthcare professionals. 
• Information about you. in your health insurer's computer system. 
• Billing information about you from your clinic/healthcare provider. 
• Most other health information about you, held by those who must follow this law. 

Providers and health insurers who are required to follow this law must keep your information private by:

• Teaching the people who work for them how your information may and may not be used and shared,
• Taking appropriate and reasonable steps to keep your health information secure. 

To make sure that your information is protected in a way that does not interfere with your healthcare, your information can be used and shared: 

• For your treatment and care coordination,
• To pay doctors and hospitals for your healthcare
• With your family, relatives, friends or others you identify who are involved with your healthcare or your healthcare bills, unless you object
• To protect the public's health, such as reporting when the flu is in your are, or
• To make required reports to the police, such as reporting gunshot wounds

Your health information cannot be used or shared without your written permission unless this law allows it. For example, without your authorization, your provider generally cannot: 

• Give your information to your employer
• Use or share your information for marketing or advertising purposes, or
• Share private notes about your mental health counseling sessions

Return Policy

We offer a 14-Day Fit and Style Guarantee, as well as a 365-Day Product Warrantee on most products. We provide free returns on all of our products during these time periods. To make a return, simply return them to our office. 

Having trouble with your glasses? We want to help you find your perfect pair of glasses. We can walk you through finding the best fit, style, and prescription correction. We are always available to adjust and fit any frames purchased at our offices without an appointment. We will also recheck vision and lens alignment. 

Glasses and sunglasses must be returned in their original condition. Returns or exchanges may be denied, in rare circumstances, based on the nature of prior transactions and condition of the product. 

Contact lenses may be returned at any time in unopened and undamaged boxes. 

Contact Lens Prescription Signed Acknowledgment Form
Included below is important information to review prior to receiving your contact lens prescription.
The Centers for Disease Control and Prevention (CDC) makes clear, “Contact lenses can provide many benefits, but they are not risk-free—especially if contact lens wearers don’t practice healthy habits and take care of their contact lenses and supplies. If patients seek care quickly, most complications can be easily treated by an eye doctor. However, more serious infections can cause pain and even permanent vision loss, depending on the cause and how long the patient waits to seek treatment.”
The CDC recommends the following for contact lens wearers:
✓ Schedule a visit with your eye doctor at least once a year.
✓ Take out your contacts and call your eye doctor if you have eye pain, discomfort, redness, or blurry vision.
✓ Understand that eye infections that go untreated can lead to eye damage or even blindness.
✓ “To be sure that your eyes remain healthy you should not order lenses with a prescription that has expired or stock up on lenses right before the prescription is about to expire. It’s safer to be re-checked by your eye care professional.”

Symptoms of Eye Infection include:
• Irritated, red eyes
• Worsening pain in or around the eyes—even after contact lens removal
• Light sensitivity
• Sudden blurry vision
• Unusually watery eyes or discharge

Sign below to acknowledge that you were provided with a copy of your contact lens prescription at the completion of your contact lens fitting and that you are willing to accept a copy of your prescription via email or a personal health records online portal.