0%

Patient Information

* required

* required

* required

* required

* required

* required

* required

* required

* required

* required

25%

Medical & Vision Insurance

Vision Plan
(e.g. VSP, Versant, Davis, Superior, Spectera, Cigna Vision)
A vision plan pays for determining a prescription for glasses/contacts and purchase of lenses. If you have medical complaints, symptoms, or a history of medical eye conditions, a vision plan will not cover services. Vision plans require that we sign their contract agreeing to this.
Medical Insurance
(e.g. Blue Cross, Aetna, Cigna, Humana, United Healthcare, Medicare)
This covers medical eye problems. Conditions such as diabetes, infections, allergies, dry eyes, cataracts, retina problems, or glaucoma mandate that medical offices are required by law to file the claim with your medical insurance. To do otherwise is considered insurance fraud.
I understand the difference between vision plans and medical insurance and agree to billing decisions made by Master Eye Associates based on these industry regulations.
Signature:
Date:
50%

Your Eye History

Yes   No   Yes, part-time
Yes   No   Yes, part-time
Yes   No

Your Medical History:

Review of Systems

Health Maintenance

Diabetic retinopathy is a serious sight-threatening complication of diabetes. Over time, diabetes damages small blood vessels throughout the body, including the retina. If left untreated, diabetic retinopathy can cause blindness. (American Optometric Association, Nov. 2023.)

Social History


Family History

75%

Patient Forms

Financial Policy & Pre-Authorization
Insurance Billing Summary
Notice of Privacy Practices
Patients will be provided a hard copy of these forms upon request.

Patient Signatures

Insurance Authorization

I authorize any holder of medical information about me to release to Centers for Medicare/Medicaid Services or my insurance companies any information needed to determine these benefits or the benefits payable for related services. I also authorize payment of insurance benefits, otherwise payable to me, directly to Master Eye Associates (TAX ID 58-2413634) for services they furnish.
Signature:
Date:

Pre-Authorized Payment Agreement

I understand and agree to the Financial Policy & Pre-Authorization Agreement. I authorize Master Eye Associates to keep my signature on file and to charge my MasterCard or VISA the balance of charges not paid by my insurance (not to exceed $500) for all professional services during the next 12 months. I assign my insurance benefits to Master Eye Associates. I understand this authorization is valid for one year unless I cancel by written notice to Master Eye Associates.
Signature:
Date:

Notice of Privacy Practices

I acknowledge that I have reviewed the Notice of Privacy Practices.
Signature:
Date:

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