If The Patient Is A Minor, The Following Must Be Completed By The Parent Or Guardian:
Each doctor is independent, Andover Eye Associates, Inc. is a billing and administrative agency.
Reason for visit:
Do you have any drug or food allergies?
Do you smoke?
Do you drink alcohol?
There is an additional fee for contact services (fitting or update) which your insurance may not cover. You are responsible for these charges at the time of service.
I have been provided with a notice of Privacy Practices and I have had the opportunity to read it.
I authorize Andover Eye Associates to release health information, not only to my doctors but also to the following individuals:
I understand that I may change this list at any time.
Medicare program standards under section 1862 (a) (a) of the Medicare law will deny payment for:
"Refraction- the determination of the best corrective lenses to be prescribed or a change in your glasses prescription (CPT Code 92015)"
I have been notified by my physician that he/she believes that, in my case, Medicare will deny payment for refraction for the reason stated above. I agree to be personally responsible for the payment.
Refraction fee if $40.
If you are here today for a Routine Eye Exam to obtain a refraction for a new eyeglass prescription (No medical problems)-we will bill your routine eye exam to your vision plan or to your health Insurance If you have a routine eye exam benefit.
If you have a complaint or medical concern you want addressed other than a need for a new eyeglass prescription, we will bill-that claim to your medical insurance. If your medical claim requires a referral it is your responsibility to obtain one from your PCP.prior to your visit.
It is 'our policy to submit the claim for service electronically usually the same day as your visit. Once submitted we are unable to make any changes.
By signing below, you acknowledge your understanding of our policy, authorize us to bill the Insurance deductibles.indicated by you, and acknowledge you will be responsible for any co-payments, co-Insurance or deductibles.
I understand that I am consenting to an office visit/treatment/procedure/surgery that is/is not urgent or emergent. I also understand that the Coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization (WHO), and that COVID-19 is extremely contagious and is believed to spread by person-to-person contact. As a result, federal and state health agencies recommend social distancing.
I understand that my provider at Andover Eye Associates has put in place what are currently believed to be the most up-to-date, reasonable safety measures to help reduce the spread of COVID-19.
I understand that even If I have received a negative COVID-19 test result, the test may have failed to detect the virus, or I may have become infected after I took the test. I understand that even if I do not have any symptoms, I may have the COVID-19 infections, and that having the elective office visit/treatment/procedure/surgery can lead to a higher chance of complication and/or death.
I understand that exposure to COVID-19 before, during, and after my elective office visit/treatment/procedure/surgery could result in any of the following: a positive COVID-19 diagnosis, extended isolation, additional tests, and hospitalization (up to and including: the need for treatment In intensive care (ICU), short-term or long-term intubation, and other complication, and death)
I understand that COVID-19 may cause additional risks, some of which may not be known at this time, and that after my elective visit/treatment/procedure/surgery I may need additional care that may require that I go to an emergency department or hospital.
I understand that any elective treatment/procedure/surgery In Itself may also require additional care, which may require that I go to an emergency department, other specialist, or hospital.
I understand that this elective office visit/treatment/procedure/surgery may put me at increased risk for becoming infected with COVID-19. By signing this consent, I have accepted that risk and give my permission to proceed with office visit/treatment/procedure/surgery I have been given the choice to have my office visit/treatment/procedure/surgery at a later date. I understand the potential risk of delaying and want to proceed. I have read this consent, or someone has read it to me.
You are being asked to sign this Privacy Authorization Form to allow Ora, Inc. access to protected health information (PHI) Ora, Inc. is an internationally renowned clinical research and development group that specializes in the development of ophthalmic (eye), topical medications and medical devices.
In order to determine if you are qualified for and/or interested in participating in clinical research trials that Ora might conduct, you will need to agree to the terms of this authorization.
I authorize Ora, Inc. and/or their administrative and clinical staff to use and disclose the PHI listed above to sponsoring drug companies or contract research organizations.
This authorization is to allow Ora, Inc. to use the information above to determine if you may be eligible for future research studies. Prior to disclosing any other PHI (like your past or present medical conditions or medications you are currently taking) for a study Ora will ask for your authorization and you would be asked to sign a separate Authorization similar to this.
This Authorization is for research and has no expiration date.
You have the right to revoke this authorization, in writing, at any time by sending a written notification to Ora's Privacy Contact at PrivacyContact@oraclinical.com or
300 Brickstone Square
Andover, MA 01810
There will be no re-disclosure of your PHI by Ora until you have signed a further authorization.
Ora will not condition treatment, payment, enrollment or eligibility for benefits (as applicable) on whether or not you provide authorization to release your protected health information to Ora unless your treatment is related to research conducted with Ora.
If you choose to sign this form, you will receive a copy of this signed authorization for your records.