Location
Which eye has the problem?
Quality
Does the problem cause vision loss or blur?
Context
Did the problem occur suddenly or gradually?
Severity
How severe is the problem?
Modifying Factors
Is it worse at any specific distance?
Duration
How long does it last?
Timing
How long has the problem been occurring
Associated Symptoms
Are there associated symptoms?
Previous Interventions
Does anything help the problem?
When do you wear your glasses?
What style are you interested in?
Please check ‘yes’ or ‘no’ for each question and write in any essential information:
Past Ocular History
Family Ocular/Medical History
Social History
Constitutional -- Do you CURRENTLY have...
Ear, Nose, Throat
Cardiovascular
Respiratory
Hematologic
Musculoskeletal
Endocrine
Genitourinary
Neurological
Skin
Psychiatric
Gastrointestinal
Immunology
I certify that I have read and understood the above information to the best of my knowledge. I certify that the above questions have been accurately answered to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health. I authorize the doctor to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such eye care to third party payers and/or health practitioners
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I understand there are risks associated with using my own frame and that Valley Eye Associates is not responsible for any damage done during adjustments or insertion of new lenses.
We make every effort to keep down the cost of your medical care.
I authorize my third party plan to pay Valley Eye Associates directly. If this is not permitted by my policy then send the check made out to Valley Eye Associates at the following address:
I authorize Valley Eye Associates to file complaints on my behalf if my third party carrier does not properly handle my claim. In order to ensure payment of my claim, I authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.
I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my health information. I understand that this information can and will be used to:
I have been informed by Valley Eye Associates and the Notice of Privacy Practices (see forms below) which contains a more detailed description of the uses and disclosures of my health information. I have been given the right to review and sign this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that Valley Eye Associates restricts how my private information is used or disclosed to carry out treatment, payment, or health care options. I also understand that Valley Eye Associates is not required to agree to my request restrictions, but if Valley Eye Associates does agree then it is bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, excluding the extent in which Valley Eye Associates has already taken action relying on this consent.
Valley Eye Associates participates with most insurance companies, but each plan varies by employer and insured. Please know your plan. Co-payments are due and payable at the time of your office visit. Deductibles, co-pays, co-insurances, and/or other balances that are your responsibility will be billed to you once these amounts are determined. If you are a member of an HMO, you are required by your plan to obtain a referral prior to your medical examination here.
If your plan requires a referral and you have not obtained one, your examination may need to be rescheduled.
You must present your insurance card at the time of your visit. If you do not have your insurance card your examination may need to be rescheduled.
You will be required to pay out of pocket at the time services are rendered. Please contact the physician and/or the office manager to discuss a payment plan, if necessary.
We require payment at the time services are rendered. Please contact the physician and/or the office manager to discuss a payment plan, if necessary before seeing the doctor.
In an effort to provide you with flexible payment arrangements, we have expanded our payment policy.
We offer the following payment options:
Please make your choice and type your name below. If none of the above apply, please see the office manager. Thank you.
Our office is fully approved and accredited user of the Visa and Master Card Health Care Program which will enable you to use your Credit Card to automatically cover amounts not paid by your insurance. You may also choose a comfortable amount to be automatically billed to your Credit Card on a monthly basis.
I authorize the release of information to determine liability for payment and/or to obtain reimbursement. I understand that if my account is not paid directly, I am responsible for the full amount and may be charged all costs including attorney/collection agency fees incurred with collection of the amount due.
I authorize the release of any medical information necessary to process claims and the release of payment to Valley Eye Associates or the physician rendering services.