UPDATED PATIENT INFORMATION PREFIX: Mr.Mrs.Miss.Dr. JRSR BIRTH DATE:* JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920191919181917191619151914191319121911191019091908190719061905 VISION PLAN INFORMATION (CHANGES ONLY) VISION PLAN: VSPDAVISSPECTERAEYEMEDNONEUNKNOWN SUBSCRIBER BIRTH DATE:* JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920191919181917191619151914191319121911191019091908190719061905 MEDICAL INSURANCE INFORMATION (CHANGES ONLY) SUBSCRIBER BIRTH DATE:* JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920191919181917191619151914191319121911191019091908190719061905 SECONDARY MEDICAL INSURANCE? YESNO I PARTICIPATE IN A FLEX SPENDING ACCOUNTI HAVE CARE CREDIT FINANCIAL INFORMATION (CHANGES ONLY) In order to control the cost of billing, we ask that the patient’s portion is paid at the time services are rendered unless other arrangements are made in advance. All professional services and materials are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance. Accounts 90 days old are subject to collection fees. There will be a service charge of $25 on all returned checks. Payment from my vision plan/medical insurance is to be paid directly to Clearfinity Eyecare Optometrist and I understand that (name of vision plan or medical insurance) will be billed as my primary insurance. I understand that billing any secondary insurance is my responsibility. I understand that all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made once the claim is processed. All eyewear purchases are final sale and only a store credit can be issued that can be used for any future eyewear purchases. PATIENT MEDICAL HISTORY (CHANGES ONLY) NEW MEDICATIONS (PRESCRIPTION OR OVER-THE-COUNTER) NEW ALLERGIES TO MEDICINES? YESNO IF SO, WHAT MEDICATIONS? ANY NEW MEDICAL DIAGNOSIS? YESNO IF YES PLEASE LIST ABOUT YOUR VISION PLAN/MEDICAL INSURANCE There are two types of health insurance that will help pay for your eye care services and products. You may have both and our practice accepts ONE or BOTH: Vision Care Plans (such as VSP, Davis, Eyemed etc..) Medical Insurance (such as Blue Cross/Blue Shield and United Health Care etc..) Vision care plans ONLY cover ROUTINE vision exams along with eyeglasses and contact lenses. Vision plans only cover a basic screening for eye disease. They DO NOT cover diagnosis, management, or treatment of eye diseases, dry eye, itchy eyes, cataracts etc... Medical insurance MUST be used if you have any eye health problem or systemic health problem that has ocular complications. Your doctor will determine if these conditions apply to you, but some are determined by your case history. If you have both types of insurance plans it may be necessary for us to bill some services to one plan and other services to the other. We will use coordination of benefits to do this properly and to minimize your out-of-pocket expense. We will bill your insurance plan for services if you we are a participating provider for that plan. We will try to obtain advanced authorization of your insurance benefits so we can tell you what is covered. If some fees are not paid by your plan, we will bill you for any unpaid deductibles, co-pays or non-covered services as allowed by the insurance contract. I have read and agree with these policies: CONTACT LENS EVALUATION FEE According to the FDA, all contact lenses are considered a MEDICAL DEVICE, since they are inserted directly on your eyes. Therefore, every year, if you want to purchase contacts or get a prescription for them, even if your prescription does not change, you must get a new evaluation for eye health purposes. This fee is separate from your regular exam that includes your eyeglass prescription and is inclusive of all contact lens related follow up visits within three (3) months. Depending on the complexity of your prescription, the type of contact lens therapy, and your insurance coverage if applicable, this NON-REFUNDABLE fee can range from $99 and up. Please check the box below if you need your annual contact lens evaluation/prescription and agree to this fee:YESNO VISUAL FIELD/RETINAL IMAGE SCREENING At Clearfinity Eyecare Optometrist, Dr. Laura Frederick believes in providing a yearly complete comprehensive eye examination, which can result in early detection of potential vision threatening and even life-threatening diseases that are not just limited to the eye.We currently have a state-of-the-art Visual Field diagnostic device which is helpful in diagnosing any potential issues that occur between the eye and the brain beyond what we can see in a dilated eye exam.The Visual Field diagnostic device tests different points of your peripheral (side) vision. Any cluster of defects found in the screening may signify a neurological concern.The most common issue that can be detected very early with a Visual Field Screening is Glaucoma.Glaucoma is a painless, slow eye disease that causes the death of optic nerve fibers resulting in gradual loss of peripheral vision over time. There is a much higher risk if an immediate family member has it.The cost of the Screening Visual Field is $29.A Wellness Retinal Imaging procedure is an additional screening tool that involves capturing an image of the back central part (retina) of your eyes. This is not an x-ray or ultrasound procedure and will not touch your eye. This permanent record is very valuable in assessing the current health of your eye. It also serves as an initial baseline from which to compare as we follow your eye health in subsequent years.The cost of the Wellness Retinal Imaging is $35Since these are screening tests, medical and vision plans will not cover it, however any abnormalities that are detected in the screening assessment will result in you returning to the office for a more extensive medical visual field test/retinal imaging that can be billed to your medical insurance minus any contracted co-pays.Together, both screenings provide a complete documented assessment of all the appearance and function of your retina. If you choose to have both screenings done it will be packaged at $59 – a $5 savings. Please place Check one of the following:YES, I want to have Visual Screening and Retinal photos for $59YES. I want only Visual Field for $29YES. I want to have only Retinal photos taken for $35.NO. I decline this additional eye health assessment.