Reason for Eye Exam
Is there any history of:
IF THE PATIENT IS A CHILD, please indicate both parents names above and fill in parent's employment status below.
Due to the HIPAA requirements, we are requesting that you provide a few names of family members
or friends with whom we can discuss your personal medical information. Thank you.
- I request that payment of authorized Medicare and/or insurance benefits be made on my behalf of CompleteEyeCare West for any services furnished me by them. I authorize any holder of medical information about me to release to the Center for Medicare Services, it's agents, or any other insurance carrier I may have, any information needed to determine these benefits or the benefits payable for related services. This assignment will remain in effect until revoked by me in writing. I further acknowledge that I have read the Notice of Privacy Practices for Complete EyeCare West.
- I understand that I am financially responsible for all charges whether or not paid by insurance. I also understandthat if I fail to provide any necessary written referral forms prior to the exam, I will be given the opportunity to pay for the exam(s) today or reschedule the appointment.
- Medicare and most medical insurances companies deny payment for refraction for glasses. I agree to be personally responsible for payment.
- I also acknowledge that for the purpose of evaluation, my pupils may be dilated. This may result in blurred vision, making driving difficult. Please ask for assistance if your vision is markedly affected.
- I further agree and consent the taking of photographs which my doctor deems necessary for medical treatment information or education purposes.