• Hillcrest Vision - Patient Forms

    Welcome to Our Practice! This information will allow us to begin the process that ensures your eye health and vision remain at their best, and that your health and lifestyle needs are met. Thank you for your help.

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  • Personal & Family Medical History

    Please note any personal and/or family medical history (parents, grandparents, siblings, children; living or deceased) for the following conditions:

  • Social History

    This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.

  • Your Medical History


  • POLICY FOR MEDICAL VISITS

     

    We often have patients that have both vision and medical insurance. They are very different in terms of the services they cover and it's important for our patients to understand these differences.

    Vision Coverage is designed mainly to cover determining a prescription for glasses, to help pay for glasses or contact lenses, and to cover a routine evaluation of the health of the eyes in a healthy patient that has no particular symptoms. It is not equipped to deal with and does not usually cover medical conditions and/or treatment plans. Similarly, medical insurance is designed for when you have a medical problem that affects the eyes, and it does not cover routine services or examinations for glasses, routine vision problems such as nearsightedness, farsightedness, and astigmatism.

    When a medical diagnosis or medical condition is present that affects your eyes, such as high blood pressure, high cholesterol, or diabetes, to name just a few examples, or you have an eye disease or eye problem such as an infection (pink eye), dry eyes, allergy, or cataracts, again, just to name a few, we must often file the claim with your medical insurance, and the copays and deductibles for the insurance will apply. Your vision plan does not cover these kinds of problems. Our office does not make these rules, they are made by the insurance companies themselves, and we must comply with them. There is often no way to know prior to your examination which type of insurance will be the right one to file your claim with. We make every effort to be on many insurance panels, both medical and vision, as we can for your convenience. If we are on your insurance companies panel, we will file those claims for you. In the event that we do not accept your medical insurance or vision plan we will provide you with an itemized receipt so that you may file a claim with your insurance yourself for reimbursement. If you have any questions please let us know.

  • iWellness Imaging Consent

  • The iWellness scan is a quick, non-invasive scan that allows the doctor to see beneath the surface of your retina. This unique technology can help our doctors detect vision threatening and systemic diseases in their very early stages, when they are most treatable. Vision threatening diseases such as glaucoma, macular degeneration, and diabetic retinopathy often have no signs or symptoms in the early stages. Our doctors recommend that ALL patients have this procedure performed, and it is especially important for people who have a personal or a family history of glaucoma, macular degeneration, or other eye diseases. It is painless and there are no side effects or light sensitivity. Any questions that you may have about your iWellness scan and the results of the scan, can be discussed with the doctor during your examination. The scan is part of your medical record and can be compared with future scans, allowing us to observe even the smallest amount of change. There is a $45 charge for this test and it is not covered by your vision plan or medical insurance. Thank you for choosing our practice to protect the health of your eyes!

  • Ocular Surface Discomfort

  • Ocular Surface Discomfort is the most frequent reason that patients visit eye doctors. Therefore, we ask that you take a few moments and thoughtfully complete the questionnaire below.

  • Report the FREQUENCY of symptoms you are experiencing:

    0= Never    1= Sometimes    2= Often    3= Constant

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  • Report the SEVERITY of symptoms you are experiencing:

    0= No problems
    1= Tolerable (not perfect but not uncomfortable)
    2= Uncomfortable (irritating but does not interfere with my day)
    3= Bothersome (irritating and interferes with my day)
    4= Intolerable (unable to perform my daily tasks)

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  • For a copy of our Privacy Practices at Hillcrest Vision, follow this link for our HIPAA Notice of Privacy Practices.

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