new patient

New Patient Form

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FINANCIAL POLICY

There are two types of insurance that will help you pay for your eye care, services, and products. You may have both types and we may be a provider for both. VISION plans cover only routine wellness exams, along with glasses and contacts. A routine exam means that there is not a medical diagnosis. MEDICAL insurance must be used for medical eye care (diabetes, cataracts, glaucoma, dry eye, conjunctivitis etc.). If some fees are not paid by your insurance, you will be responsible for them (such as deductibles, co-pays, or non-covered services allowed by insurance contract). If we do not accept direct payment from your insurance, you will need to provide payment the day of service and submit a receipt for reimbursement from your insurance. By signing below, I am stating I understand the differences between vision plans and medical insurance as described above. I further accept full responsibility of any fees incurred for services provided that are not covered by my insurance company(s) Payment is due for services rendered same day, including insurance co-payments and unmet deductibles. Professional fees, such as exam fees or contact lens evaluation fees, are not refundable. If ordering materials (eyeglasses or contacts), payment in full is required before ordering materials. Prescription eyeglass lenses are custom made devices made for you and only you. Such individualized items are exclusive to each patient, and as such, cannot be returned, repurposed, or refunded.

RELEASE AND RECEIPT OF INFORMATION

By signing below, this acknowledges the Receipt of Privacy Practices, I acknowledge and agree that I have received, read and understood the Notice of Privacy Practices for review on the date identified below. I understand that Eye Society Boutique may use and disclose the necessary personal health information to another party to permit Eye Society Boutique to perform administrative duties, provide eye care and services, process my insurance claims, and communicate with me regarding eye care services.

ACKNOWLEDGEMENT OF PRIVACY PRACTICES

By signing below, I acknowledge receipt or the opportunity to review the Notice of Privacy Practices of Eye Society Boutique. In addition, by signing, I authorize Eyes on Evesham, LLC to disclose my health information in conformance with the provisions of the Notice of Privacy Practices. By signing below, I authorize the following names to discuss and participate in any medical. This will remain in effect until terminated by me in writing.

CANCELLATION/NO SHOW POLICY

If you need to reschedule or cancel an appointment, we require a MINIMUM of 24 Hours cancellation notice. Adequate notice allows us to offer the appointment to another patient. Please remember that confirmation reminders from us are only a courtesy, our failure to confirm your visit does not relieve you of your responsibility to cancel your appointment. $25 Fee will be charged when a patient fails to provide us with at least 24 hour notice of cancellation, or is a "No Show" for a scheduled appointment. ALL Fees, which are your responsibility, are due at the time of your appointment. These include any copayments, refractions, co-insurance, deductible, or any other charges not covered by your insurance. Please note that these charges are NOT billable to your insurance and are your responsibility. All fees must be paid before your next appointment.

CONTACT LENS POLICIES

A contact lens is a medical device in contact with the tissues in the eye; therefore, it must fit appropriately to maintain the health of your eyes. A contact lens prescription can only be determined by the careful observation of the lens on the eye and the eye’s response to the lens on follow up visits. All contact lens prescriptions must be finalized within 90 days of my initial appointment. Since follow up care is essential, it is your responsibility to schedule and keep appointments and follow all lens care instructions. We will not finalize the contacts lens prescription until both the patient and doctor are satisfied with the fit and visual acuity of the contact lens. All new wearers must be able to remove and insert their contacts lenses without assistance before leaving the office with them. I agree to receive texts and/or emails from contact lens distributors in regard to my contact lens orders. A contact lens prescription is valid for one year. All patients are required by law to come in for annual contact lens evaluations and corneal evaluations before a contact lens prescription can be issued. This is necessary to ensure the patient’s eyes are healthy and the contacts are fitting well. Contact lens prescription fees vary based on how complicated the evaluation will be. First time soft contact lens wearers can expect contacts lens fees to start at $65. The consult fee for established soft contact lens wearers ranges from $45-$85 based upon the complexity of the evaluation. Contact lens evaluations are a separate charge and NOT covered by your routine vision or medical insurance.

Digital Retinal Photography


We are proud to provide patients with a highly advanced Digital Retinal Photographic exam, which scans the retina to rule out or screen for eye diseases and dramatically improve our ability to view your internal retinal health. We are concerned about retinal problems such as macular degeneration, glaucoma, and retinal disorders. Additionally, systemic diseases such as diabetes and the effects of high blood pressure can be detected during a retinal exam. All these conditions can lead to vision loss. Our goal is EARLY DETECTION. This technology helps diagnose and document diseases. We are recommending a Digital Retinal Photo once a year so we can view and record your retina. You can expect:

  • An annual wellness screening photo

  • An in-depth view of the retina

  • The ability for the doctor to review the images with you

  • A record in your medical file for serial analysis, comparisons, and diagnosis

ep246 none 9:30am - 6:00pm 9:30am - 6:00pm 9:30am - 5:00pm 9:30am - 5:00pm 9:30am - 3:00pm Closed Closed optometrist # # # https://www.4patientcare.ws/v5dn/ws/wsv3p.aspx?CoverKey=6171&TaskKey=184343&LocKey=15938&V4Scenario=3&Source=website&ReferredBy=website