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Routine vs Medical


*Effective 02/19/25, in order to continue providing the highest level of patient care which we are committed to, and remain compliant with your insurance guidelines, the following policy has been implemented:

Determination of Routine vs. Medical

    1) Routine Eye Exam is defined by insurance companies as "an office visit to check vision, screen for eye disease, and/or update eyeglass or contact lens prescriptions." Routine Eye Exams produce a final diagnosis like - nearsightedness, farsightedness or astigmatism.

    • Vision plans provide coverage for Routine Eye Exams, Refractions (determines your prescription), Glasses, and/or Contact Lenses.

    2) Medical Insurance provides coverage for medical conditions that are new or already exist such as diabetes, cataracts, dry eye, glaucoma, floaters, vision loss, ocular allergies, foreign bodies in the eye, etc.

    • Exams of patients using medications with potential eye side effects, such as steroids, Topamax, or Plaquenil will be filed to your medical insurance carrier. Proper diagnosis, management and treatment will be communicated with another physician.
What happens if my exam is considered medical?
  • A claim will be filed with your medical insurance carrier and any copays or deductibles for that insurance will apply.
  • Any non-covered service like the refraction (determines your glasses prescription) will be your responsibility.
What if you are not a provider for my Vision and/or Medical insurance?
  • If we are unable to file a claim directly for you, we will provide you with an itemized receipt so you can submit for reimbursement. In order for us to help maximize your benefits, it is important for you to provide both you vision and medical insurance at time of scheduling.

Demographics


Patient Information
Title First Last MI Suffix Nickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex
Marital Status Employer / School Name
Misc/Guardian Drivers License #



Medical History


Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Primary Care Physician
Last Medical Dr Appt
Last Eye Exam
Last Eye Dr
Pharmacy

Smoking Status
Alcohol Use
Illegal Drug

Race
Preferred Language
Ethnicity

Currently pregnant or nursing


Patient Ocular History

Patient Ocular Conditions (e.g. dry eyes, cataracts, floaters, glaucoma, macular degeneration etc.)
Ocular History (e.g. eye injuries, eye surgeries, retinal detachment etc.)
Eye Medications (e.g. prescription or over the counter eye drops)

Patient Medical History

Endocrine:
If Diabetic: YrDx A1c
Allergic/Immunologic:
Musculoskeletal:
Cardiovascular:
Constitutional(Current):
Ears, Nose, Throat:
Gastrointestinal:
Genitourinary:
Integumentary (Skin):
Lymphatic/Hematologic:
Neurological:
Psychiatric:
Respiratory:
Cancer:
Other:
Other Patient Medical Conditions

Medications - No current medications
Allergies - No known drug allergies


Family Ocular History

Glaucoma
Macular Degeneration
Retinal Detachment
Cataract
Amblyopia / Strabismus
Blindness
Other Family Ocular Conditions

Family Medical History

Diabetes
Hypertension
Thyroid
Heart Disease
Cancer
Other Family Medical Conditions - Family History Unknown

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