Patient Welcome Form

General Patient Information

AUTHORIZATION AND FINANCIAL RESPONSIBILITY:

I authorize Today’s Vision to release any information including the diagnosis and records of any treatment rendered to me or my dependent during such period of eye care to any third party payers and/or health care practitioners. I authorize and request my insurance company to pay directly to Today’s Vision any benefits otherwise payable to me. I understand that in the event my insurance does not fully pay for services and/or materials rendered to me, I agree to be responsible for payment of all balances on my or my dependent’s behalf.

In order for our clinic to file your medical and vision insurance appropriately, we must have a copy of your current medical insurance card and Driver’s License and must have the name of your vision insurance plan. If the comprehensive eye exam is covered by the medical and vision plans, our policy is to bill the medical insurance first.

I certify that I have read and understand the above information to the best of my knowledge. I understand that all fees for professional services shall be paid at the time of service and are NON-REFUNDABLE. I am also aware that prescription eyeglasses are a custom order. Therefore, any cancellation will result in a 25% service charge on the order.

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES (‘NPP’)
I acknowledge that I have received and/or read a copy of Today’s Vision’s Notice of Privacy Practices.

At Today’s Vision River Oaks, we are committed to the early detection and prevention of eye diseases that can lead to serious progression and vision loss. In our continued efforts to provide the highest level of eyecare, and to bring the most advanced technology available to our patients, we are proud to perform the following Advanced Preventive Medical Health Tests for ALL annual routine eye exams:

EYESCREEN PHOTOGRAPHY: The OPTOMAPis a NEW State-of-the-art technology that gives similar results to eye drops and dilation. It consists of a high resolution (10.1 megapixels) photograph that digitally maps the back of the retina within seconds. This is a critical component of the eye exam that enables the doctor to detect early signs and changes of ocular disease such as diabetes, hypertension, glaucoma, cataracts, macular degeneration, and certain types of tumors. It also gives a baseline image to permanently add to your medical file and allows the doctor to perform a serial analysis of any changes over time. [$39 copay]

VISUAL FIELD ANALYSIS: This highly computerized instrument provides an analysis of your peripheral fields of vision. By detecting abnormal blind spots, a visual field screening can assist the doctor in the early detection of glaucoma, retinal abnormalities, neurological diseases, and possible causes of headaches. [covered]