Submit Form / Patient Signatures
HIPPA: Acknowledgment of Receipt of Privacy Notice
By signing this acknowledgment of Receipt of Notice of Privacy Practices (the "Notice"); I
acknowledge and agree that I have received a copy and/or read a copy of the Notice of
Privacy Practices for review and to keep for my records on the date identified below.
I understand that the office may use and disclose necessary personal health information (for
example, my name, address, subscriber identification number, eye exam information and/or
type of products provided) to another party to permit the office to perform its
administrative duties, provide me with eye care services and products, process my
vision/medical benefit claims and communicate with me regarding vision/medical claims and
communicate with me regarding vision/medical care services provided by the office (for
example, mailings of exam reminders or information for services/products provided by the
office).
I can be assured that this office does not sell my personal health information of any kind
to a third party for such party's own use. I authorize the office to submit my
vision/medical benefit claims to my plan sponsor or health plan to receive reimbursement
directly for the vision/medical services/products that I have received from the office.
Patient Lifetime Signature or Patient's Legal Representative Date:
INSURANCE SIGNATURE ON FILE
I certify that the information given by me in applying for insurance and/or Medicare payment
is true and correct. I authorize my doctor to act as my agent in helping me obtain payment
of my insurance and/or Medicare benefits, and I authorize payment of these benefits directly
to the doctor on my behalf for any services and materials furnished. I authorize any holder
of medical information about me to release to the Health Care Financing Administration and
its agents any information needed to determine these benefits payable to related services.
If I have other health insurance coverage, my signature authorizes release of the above
medical information to the insurer or agency shown, and authorizes my doctor to act as my
agent, as above.
I understand I am responsible for the balance of fees not paid by my
insurance.
Patient Lifetime Signature or Patient's Legal Representative Date:
REFRACTION POLICY: * FOR INSURED PATIENTS ONLY *
The Centers for Medicare and some insurance companies consider a refraction to be a
NON-COVERED service. Please be aware it is the responsibility of the patient
to pay for the refraction unless otherwise stipulated by your insurance carrier. Our office
currently charges
$95.00 for this procedure, but provides a prompt pay price of
$45.00 to the patient when paid at the time of service. The refraction fee is paid in
addition to the eye exam co-pay. I have read the above information and understand I may be
charged a prompt pay price of $45.00 at the time of service unless otherwise stipulated by
my insurance company.
Patient Lifetime Signature or Patient's Legal Representative Date:
Electronic Communication
Please be advised that any communications we received from you, the patient, through
electronic means, such as text or email, will be unsecured. Our office will not send any
health or medical records to you through these channels, unless requested by you. Our office
will always strive to protect your records through proper means.
By signing this, you fully have understood and accepted all the risks involved in an open
channel communication.
By entering my name below, I agree to all of the above and I accept this as my digital signature
Patient Lifetime Signature or Patient's Legal Representative
Date:
Dilated Fundus Exam:
Dilation provides a more comprehensive internal ocular health analysis of the eye. The side
effects include temporary blurry vision at near, some blur at distance and light
sensitivity. This procedure is included with your comprehensive exam. There is a
$25
FEE charge charge if patient have this procedure after 30 from the time
of exam.
Yes. I want the
Dilated Fundus Exam
I will ask the Doctor
Optomap Retinal Exam:
An effective computerized imaging that scans 80% of your retina to help your Doctor
evaluate, monitor, and treat various eye conditions. Our staff will scan your eye at the
time of your exam, and your doctor will ask to review the images. If you agree to the
viewing,
there is a $45 FEE for the Doctor to review the images with you.
Yes. I want the Dr. to review the
Optomap I will ask the Doctor
Visual Field Analyzer:
A visual field screening can assist us in early detection of glaucoma, retinal problems, and
some neurological diseases and may diagnose causes of headaches.
There is a $25.00 fee
for the visual field screening.
Yes. I want the
Visual Field Analyzer
I will ask the Doctor
Refund/Remake Policies
- We will make your lenses according to your Doctor's written prescription. Our goal
is to provide the highest quality products and the best possible service.
- We CANNOT CANCEL your order or REFUND your lenses after your lenses has been
ORDERED/ PROCESSED including partial deposits.
- Patient understands that frame choice is FINAL once the lenses have
been processed
- Patients experiencing adaptation issues to any prescription MUST
return within 30 days from the date of purchase for a
1 time remake.
- No Refunds will be given to patients that do not adapt to their
prescriptions. We offer to REMAKE the lenses within the 30 days from
the date of your order.
- Ella Eyes standard policies include 30 days of customer
satisfaction in which we will gladly adjust, repair, or equally
exchange your new glasses if there are any defects.
- We offer a one time, within the year of purchase, a SCRATCHED lenses warranty of
the same RX REMAKE at no charge.
- We offer to replace your BROKEN OR DAMAGED glasses 1
time with the same or equivalent product at a 50%
off retail pricing up to 1 year from the date of your
purchase. We do not cover lost or stolen glasses.
**Patient acknowledges receipt of Ella Eyes @ Woodway Collection "Remake & Refund
Policies" and fully understands the policies.**
Patient Signature or Patient's Legal Representative Date
All PROFESSIONAL SERVICES ARE DUE AT TIME OF SERVICE AND ARE NON-REFUNDABLE
**There is no fee for follow up visits on glasses or contact lens fitting within 30 days
from initial exam. Any follow ups on glasses or contact lens past 30 days will be
charged an office visit fee.
By entering my name below, I agree to all of the above and I accept this as my digital signature:
Patient Signature or Patient's Legal Representative
Date
Contact Lens Service Agreement
Contact lens wear is a type of correction that requires commitment and good hygiene. Not
everyone can wear contact lenses successfully. There are many factors that can influence the
success of your fit such as allergies, oily tears, dry eyes, medications, improper care or
failure to return for follow-up visits. It is not always possible to determine in advance
whether you will be those who will successfully enjoy contact lens wear.
Even with the
best fit, contact lens vision, in some cases, may not be as clear and comfortable as
spectacle wear.
Eye Infections can occur even with proper contact lens usage and care. Contact lenses
can also cause red eyes, blurred vision, light sensitivity, itchiness, mucus build-up, and
can become uncomfortable.
Lenses should not be worn if these conditions occur. If
these conditions occur, an
OFFICE VISIT should be made immediately.
Follow-up visits are extremely important.
It is the patient's responsibility to return to
the doctor when the contact lenses are dispensed and for routine follow-up visits per
the doctor's instructions. It is also necessary for the patient to return for a
routine eye exam every 12 months or sooner as all spectacle/contact lens prescriptions will
expire one year from the date of the initial exam unless specified by the doctor.
The contact lens exam includes an eye exam, contact lens fitting, and (3) follow-up
visits for one month per doctor's instructions, from the initial date of the
exam. If the patient does not return for the scheduled visits within the allowed time,
then there will be a fee accrued for visits after the month is up.
All fees charged for the EXAMINATION, FITTING, and SERVICE AGREEMENT (conventional,
disposable, and planned replacement) are NON-REFUNDABLE.
I HAVE READ, UNDERSTOOD, AGREED to the ABOVE CONTACT LENS AGREEMENT
Patient Signature or Patient's Legal Representative Date
Contact Lens Digital Consent
I authorized my eye doctor to provide me with a digital copy of my contact lens prescription
by,
Patient Portal (Most Secure)
Email
Text
at the end of my contact lens fitting.
Patient Signature or Patient's Legal Representative
Date