Patient Privacy Notice Summary:
Initialing this section signifies you have received a copy of our Notice of Privacy Practices.
I hereby authorize and consent to medical treatment by Optic Gallery Stephanie St. for myself. I authorize Optic Gallery Henderson LLC . to release my medical information to my family doctor and to any insurance company, adjuster, attorney, authorized agent working on my behalf of Optic Gallery Stephanie St. or other authorized party. I understand that I am responsible for payment of all vision and medical treatments rendered to me by Optic Gallery Stephanie St. and I agree to pay all co-payments, deductibles and non-covered service fees in full at the time of the visit. I understand that, as a courtesy to me, Optic Gallery Henderson LLC. will file a claim with my insurance carrier, and I authorize payment directly to Optic Gallery Henderson LLC . for the benefits otherwise payable to me under the terms of my insurance. I understand that I am responsible for maintaining my current coverage information, to meet filing deadlines and for the payment of any remaining balance after payment from my insurance carrier. I authorize pertinent medical information about me to determine insurance benefits and billing to be released to the health care financing or other insurance agencies. I understand that should my financial account become delinquent, it will be sent to collections where I will be responsible for any collections fees, attorney fees, and court costs. I also understand that all eyewear, services, and supply sales are final and there will be no refunds issued.
Digital Retinal Photography (DRP):
The D.R.P is a digital view of the back of your eye in a high definition picture format, which is saved into your patient file in our office. This scan can be viewed immediately and examined by the Doctor during your exam. The D.R.P allows the Doctor a much wider field of view than most traditional retinal exams. We save your photos onto our computer as it serves as documentation of the current condition of your eyes which can aid in the tracking of any changes over the years should anything occur in the future. The Doctor strongly recommends that the patients of our office have this procedure done to allow him/her to utilize all tools available to assess the health of the eyes, especially if any of the following apply: diabetes, cataracts, high blood pressure, frequent or severe headaches, high nearsightedness, symptoms of flashes or floaters, personal or family history of glaucoma, or if you are over the age of 40. The entire procedure takes less than five minutes to complete in most cases. There are no side effects to this procedure like those normally associated with dilation. The charge for this procedure is $30.00 and it is not covered by most insurances. If you have any further questions or concerns, the doctor will be happy to address those with you during the exam.
Contact Lens Evaluation Fees:
Contact lenses are medical devices that require a comprehensive vision and eye health evaluation before they are prescribed in order to determine that contact lenses can be worn safely for the following 12-month period. The contact lens evaluation fees collected at the initial exam will cover any necessary follow-up visits within 60 days from the contact lens evaluation to ensure you are completely satisfied with the vision and comfort of your contact lenses. The out of pocket cost for this service is $75, but a portion may be covered depending on your insurance coverage.
I have read and understand the above office policies regarding billing, refund policy, HIPAA, Medical Services, DRP, Release of Medical Records, Contact Lenses and Materials at Optic Gallery Stephanie Street.
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