PLEASE READ THIS ELECTRONIC SIGNATURE CONSENT BEFORE YOU PROCEED
Your electronic signature shall have the same force and effect as an original signature and shall be deemed
(i) to be "written" or "in writing" or an “electronic record”
(ii) to have been signed and
(iii) to constitute a record established and maintained in the ordinary course of business and an original written record when printed from electronic files. Such paper copies or "printouts," if introduced as evidence in any judicial, arbitral, mediation or administrative proceeding, will be admissible as between the parties to the same extent and under the same conditions as other original business records created and maintained in documentary form.
- An important part of your eye exam, is the retinal evaluation. It enables the doctor to evaluate the health of your body by looking at the blood vessels, nerves, and other layers inside your eye.
- This evaluation is recommended once a year for all patients.
- This evaluation is mandatory for
- Patients with vascular diseases (Diabetes, High Blood Pressure, High Cholesterol)
- Patients with high myopic prescriptions (Over - 4.00)
- Patients over 40 years of age.
- Patients using medications that have ocular side effects (e.g. Plaquenil, Ethambutol, Topamax, Flomax, Blood Thinners, and herbal supplements)
- You may either get your eyes dilated using eye drops, or use the OPTOMAP retinal imaging system. The OPTOMAP Imaging System is a fast, Comfortable, and Painless digital imaging of the retina without the use of eye drops:
Please select one of these three options:
- I would like Optomap retinal imaging. I agree to the $39.00 fee for service. I understand that this technology is not covered by my insurance.
- I would like a Total Wellness Scan that includes Optomap retinal imaging and baseline testing for Macular Degeneration and Glaucoma. I agree to the $59.00 fee for service. I understand that this technology is not covered by my insurance.
- I prefer dilation with eye drops. I understand that my near vision will be blurry, and my eyes may be light sensitive for up to 3 hours. I understand that I am not supposed to drive more than 5 miles, or operate any machinery until I feel like my vision has suitably recovered.
Examination and Billing Protocols
- Payment is due in full at the time of service and purchase. Payments made toward services offered at Richmond Eye Experts are non-refundable.
- You must present your insurance information before or on the day of your visit. The decision to bill your vision insurance vs. your medical insurance depends on the reason for your visit and severity of eye condition when you present for your exam.
- Your complete comprehensive eye exam will be conducted at the time of your appointment. Declining the internal eye exam will require a signed consent and is NOT ADVISED. Delaying the internal eye exam to another day will incur an additional office visit fee of $50.00.
- Contact Lens exams will involve additional fees. These fees are dependent on your insurance company. Please ask the staff for details. If you sign up for a contact lens exam, this fee will be collected even if you do not purchase the lenses, or complete the fitting process. Contact Lens exams may require follow up exams on a separate date for no extra charge. Follow up exams should be maintained as scheduled, and prescriptions should be finalized within 60 days of the initial visit. If the process takes longer due to noncompliance with follow up exams, then there will be an additional contact lens examination fee payable by the patient.
- If you are not comfortable with your glasses, we will do one complimentary prescription recheck within 30 days of the initial eye exam. There will be a $35.00 refraction fee for prescription verifications after 60 days of the visit. Rechecks will NOT be provided after 2 months of the exam. This will be considered a new exam.
Notice of Privacy Practices: PLEASE READ CAREFULLY
- We will use your health information for referrals to other physicians for your continued care, to provide appointment reminders, prescribe or recommend treatment alternatives, and provide information about health benefits and services that may be of interest to you.
- We will email your prescriptions and referrals via the patient portal to the email address you have provided on this form. We are unable to merge portals or change email addresses over the phone.
- Please review the complete patient privacy notice. Signing this document acknowledges that you were offered the opportunity to review this policy.
Authorization and Consent: PLEASE READ CAREFULLY
- I certify that I have filled out the patient information form accurately and to the best of my knowledge.
- I authorize the eye doctor to release any information including the diagnosis and records of any care rendered to me, to third party payers/ health practitioners for the purposes of checking eligibilities, payment or continued care.
- I attest that the address, phone number, and email address provided is mine, and Elite Family Vision can contact me to remind me of appointments, mail patient information including prescriptions, Optomap images, and balance payable notices to any of the above.
- I authorize and request my insurance company to pay directly to the eye doctor, the benefits otherwise payable to me. I understand that my insurance carrier may pay less than what is billed, and I may be responsible for uncovered balances, copays, coinsurance payments or deductibles that are not covered under insurance contracted amounts.
- I understand that if the insurance company accidentally pays me directly for the services, I will issue a payment to the billing facility.
- I understand that I will not receive prompt pay discounts or special pricing when I use my insurance for payment toward the eye exam.
- I understand that there are no refunds for professional services rendered. Prescription glasses are custom made products, and as such, once the order is transmitted to our lab, it cannot be cancelled or refunded at any time.
- I hereby authorize Elite Family Vision to bill my vision and/or medical insurance on my behalf and collect payment for services rendered.
- I understand that balances will be forwarded to a collection agency if not paid within 90 days after three attempts to contact me via phone, text, or email. An additional administration fee of $25 will be added to bills that require to be mailed.
- I understand that this office is HIPAA compliant and acknowledge that the HIPAA policies are available here. This authorization and consent to use my Protected Health Information is valid for 6 years until revoked in writing.
- I understand that Elite Family Vision may refuse treatment if I do not consent to the above protocols, notices, and authorizations.