Total Vision DeBary - Patient Forms

Insurance Information
LIFETIME INSURANCE AUTHORIZATION
MEDICARE AND ACCEPTED MAJOR MEDICAL INSURANCE

I request that payment of authorized Primary and Supplement Insurance benefits be made either to me or on my behalf for any service furnished by my doctor at Total Vision. I authorize any holder of medical or other information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits for related services.

The coronavirus has changed our world and we are evaluating how we can protect our patients by following CDC guidelines and still provide an exemplary eye health exam. We are strongly recommending that all patients get both tests listed below to minimize the time spent in the office, minimize the patient contact using dilation drops yet still provide the Doctor with the necessary view of your eye.

Test Descriptions:

CenterVue Eidon Retinal Scan.

We take an extremely high-quality digital photo (of most patients) to see a wide view of the retina to evaluate the health of your eyes. It has already enabled us to detect problems we would have otherwise missed. The pictures will be kept in your file for comparisons at future eye exams and we recommend them every year. This is a great addition to dilation, but not a substitution. Dilation is recommended every 2 or 3 years unless you are in a high-risk category.

These are additional screenings that are NOT COVERED BY ANY VISION OR MEDICAL PLAN
Please arrive a bit early to your appointment.

Yes, I choose to have the test and agree to pay an additional $39.00 today.I would like to discuss other options with TVEH team
Signature - Parent or guardian, please sign if patient is less than 18 years old.

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