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Medical History
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Eye History
Contact Lens Wearers only:
Medical History:
Do you have any of these medical conditions?
Family Medical History
Does anyone in your family have any of these medical conditions?
Family Eye History
Does anyone in your family have any of these eye conditions?
Review Of Systems
Social History
Office Policies and Practices
Financial Responsibility
Thank you for choosing Central Eyes. As a courtesy to you, we will submit the billing
for today's services to your insurance carrier if we are a participating provider for
that plan. Any balance not paid by your insurance carrier is your responsibility, and
you will receive a statement for payment. If you do not inform us that you have a vision
plan or medical insurance before services are rendered, we will assume no coverage
exists and you will be responsible to file your own claim. We accept Discover,
MasterCard, Visa, American Express, checks, cash, and two financing options; Cherry &
CareCredit as forms of payment. Any co-payments, deductibles, co-insurance will be
collected at the time of your appointment.I understand that full payment is due at
the
time services are rendered, all sales are final and no refunds are given. For
delinquent
accounts, I am responsible for any reasonable collection fees incurred by Central Eyes
to collect payment for materials and/or service rendered.
Consent for Use and Disclosure of Health Information
I understand that the privacy practices of Central Eyes are in compliance with the
Health Insurance Portability and Accountability Act (HIPAA). I acknowledge that I may
request a copy of this Act from the front office staff. I have had full opportunity to
read and consider the contents of the Consent form and Notice of Privacy Practices. I
understand that by signing this Consent form, I am giving my consent for Central Eyes'
use and disclosure of my protected health information to carry out treatment, referrals,
payment activities, and health care operations. We may disclose your health information
to an optician, ophthalmologist, or other health care provider providing you treatment.
Insurance claim information is transmitted via a secure internet connection. Central
Eyes may also send me text messages and email correspondence, such as recall notices. I
authorize Central Eyes to contact me by telephone or other media devices for
communications needed to monitor my progress.
Contact Lens Patient Agreement
Please be aware that the evaluation and management of contact lenses is performed in
addition to your eye exam and there is a separate fee for this service. This service
must be performed within 3 months of your comprehensive exam or an additional refraction
and contact lens evaluation fee will apply. The evaluation and management fee is based
on the type of contact lenses prescribed and the complexity of the fit. Two follow ups
within 60 days of your initial visit is included in your fitting fee. A contact lens
prescription and a glasses prescription will be provided at the end of the examination
for you to purchase at our office. Doctor fees are considered non-refundable for the eye
exam and contact lens fitting due to the professional services and office time provided.
Cancellation Policy
Our goal is to provide quality health care to all our patients in a timely manner.
No-shows, late arrivals, and cancellations are not only an inconvenience to our
providers, but to other patients as well. When you book your appointment, you are
holding a space on our schedule that is no longer available to other patients.
If cancellation is necessary, we require that you call or text 727-321-6600 at least 24
hours in advance. Appointments are in high demand, and your advanced notice will allow
another patient access to that appointment time. A $40 cancellation/no show fee will be
assessed at your visit if notice is not provided.
By signing below, I agree to the office's policies and practices.