Intake Online Form Oprima aquí para español HiddenDate MM slash DD slash YYYY Location*please select your locationSugar Land, TXWharton, TXNorth Shore, HoustonThe Woodlands, TXName First Last Date of Birth MM slash DD slash YYYY Age Sex Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Occupation Cell NoHome NoParent’s or Guardian’s name if patient under 18 years of age, and in case of emergency, who we should contact Name Relationship PhoneHow will you be paying for your visit today? Medical Insurance Vision Insurance Self-pay WHAT IS THE PURPOSE OF YOUR VISIT TODAY? Wellness Check/Glasses Wellness Check/Contact lenses Both Ocular History (please CHECK all that apply) healthy, no complaints blurred vision without correction lazy eye headaches/eye strain double vision eye injury eye surgery flashes of light floaters other please explain Medical History (please CHECK all that apply) healthy, no medical conditions heart disease diabetes glaucoma asthma high blood pressure thyroid other Please list Family Medical and Ocular History (please CHECK all that apply) healthy, no medical conditions heart diseaseList: (Who Mom/Dad etc.) high blood pressureList: (Who Mom/Dad etc.) diabetesList: (Who Mom/Dad etc.) glaucomaList: (Who Mom/Dad etc.) cataractsList: (Who Mom/Dad etc.) othersplease list List all drug allergies List all medications being taken Are you pregnant? Yes No Are you nursing? Yes No Tobacco Use? Yes No Alcohol Use? Yes No How did you hear about us? Friend Vision Center Banner/Sign Newspaper PLEASE READ CAREFULLY Dilation: Dilation is the opening of the pupils by using medicated eye drops. This allows a better view of the retina and helps the doctor to detect many eye conditions that may be missed during a routine eye exam. Dilation is strongly recommended for patients with a history of cataracts, high blood pressure, high prescriptions, and patients older than 40. However, dilation is mandatory for all diabetic patients, patients with a history of glaucoma, and children 12 and under. After being dilated, you may experience blurred near vision and light sensitivity. These side effects can last from 3-6 hours. There are no additional fees for the test. Yes I would like to be dilated todayBy signing below, I understand and release Riz Eye Care and their doctors from all liability to treat or diagnose any eye condition due to lack of diagnostic information that could have been obtained from dilation. No, I do not want dilation.By signing below, I understand and release Riz Eye Care and their doctors from all liability to treat or diagnose any eye condition due to lack of diagnostic information that could have been obtained from dilation.Patient/GuardianADDITIONAL TESTS – PLEASE READ CAREFULLY Visual Field: Computerized device used to test your peripheral vision. This test helps detect vision loss caused by glaucoma, retinal disease, stroke, injuries to the head, in addition to certain medications such as Chloroquine, Seizure medications, Antidepressants etc. that cannot be detected with a comprehensive dilated exam. With early detections, this test can prevent many blindness-causing diseases before it is too late. This test does not require eye drops and takes 3-5 minutes to perform. The cost of this procedure is an additional $20 (If using insurance the cost of the VF will be $20) Yes, I would like to have it done today No, I declinePatient/GuardianOFFICE POLICY All visits to the office are due and payable at the time of service All fees are for professional services and therefore are non-refundable Contact lens exam fees include up to 2 follow up visits within 30 days from the date of initial examination I have received and read the Notice of Privacy Practices (HIPAA) I agree to all of the terms mentioned abovePatient/GuardianSIGNATURE ON FILE, ASSIGNMENT OF BENEFITS, FINANCIAL AGREEMENT, HIPAA NOTICE HIPAA NOTICE OF PRIVACY PRACTICES: I acknowledge that I have received the Notice of Privacy Practices issued by Riz Eye Care that was effective April 1, 2005. for more information visit www.rizeye.com RELEASE OF INFORMATION: Riz Eye Care may disclose all or part of my medical record and/or financial ledger, including information regarding alcohol or drug abuse, psychiatric illness, communicable disease, or HIV, to any person or corporation (1) which is or may be liable or under contract to Riz Eye Care for reimbursement for services rendered, and (2) any health care provider for continued patient care. A copy of this authorization may be used in place of original. NON-COVERED SERVICES: I understand that Riz Eye Care contracts with health care service plans (i.e., HMO’s, PPO’s) relate only to items and services which are “covered” by health care service plans. Accordingly, the undersigned accepts full financial responsibility for all items or services, which are determined by the health care, service plans not to be covered, including refraction fee (which is not covered by Medicare). I agree to cooperate with Riz Eye Care to obtain necessary health care service plan authorizations. FINANCIAL AGREEMENT: I agree that in return for the services provided to me by Riz Eye Care, I will pay my account at the time service is rendered or will make financial arrangements satisfactory to Riz Eye Care for payment. IF my account is sent to an agency for collection, I agree to pay collection expenses and reasonable attorney’s fees as established by the court and not by a jury in any court action. I understand and agree that if my account is delinquent, I may be charged interest at the legal rate. Any benefits of any type under any policy of insurance are hereby assigned to Riz Eye Care. If co-payments and /or deductibles are designated by my insurance company or health plan, I agree to pay them to Riz Eye Care. However, I understand that I am primarily responsible for the payment of my bill. MEDICARE: I request that payment of authorized Medicare benefits be made on my behalf to Riz Eye Care, for services furnished to me by Riz Eye Care. I authorize any holder of medical information about me to release the centers for Medicare and Medicaid services and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorized release of medical information necessary to pay the claim. If other health insurance is indicated in Item 9 of the HCFS 1500 form or elsewhere on other approved claim forms, my signature authorized releasing the information to the insurer or agency shown. Riz Eye Care accepts the charge determination of the Medicare carrier as the full charge, and I am responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and deductible are based upon the charge determination of the Medicare carrier. MEDIGAP: I understand that if a Medigap policy or other health insurance is indicated in Item 9 of the HCFA 1500 form or elsewhere on other approved claim forms, my signature authorizes release of the information to the insurance or agency shown. I request that payment of authorized secondary insurance benefits be made on my behalf to Riz Eye Care, if possible, or otherwise to me. OTHER INSURANCE: I authorize payment of my medical and surgical insurance benefits to Riz Eye Care. I understand that I am financially responsible for any charges whether or not paid by said insurance. If co-payments and/or deductibles are designated by my insurance company or health plan, I agree to pay them to Riz Eye Care. Patient/Guardian SignatureThe Difference in Vision Care Fees & Medical Care FeesTo avoid misunderstanding and confusion about our professional fees for Vision Care vs. Medical Care, please read and sign the following: No Insurance Coverage If you are healthy and have healthy eyes, wellness eye exam fees will be charged for your eye exam and/or contact lens exam to correct your nearsightedness or farsightedness or astigmatism or presbyopia. If you have a general health problem or an eye disease then medical eye exam fees will be charged for your medical eye care. (Further explanation under Medical Insurance below) Vision Plan and/or Medical Insurance Many Patients have vision plans and many have medical insurance coverage for their eye care, some have both. Your eye care problem will determine which Insurance Carrier we will file with for your eye care visit. Often, there is no way to know before your examination which type of insurance we file. If you have questions about your insurance coverage and/or your eye care fees, please feel free to discuss them with our staff or doctors. A Vision Plan A Vision Plan will pay for your wellness eye exam if you are healthy and have healthy eyes. The results of your wellness eye exam are used to correct vision problems such as; myopia, hyperopia, astigmatism and/or presbyopia. A Vision Plan usually (but not always) requires a co-pay if you are examined for contact lenses. A Vision Plan does not pay for your examination if the examination requires medical decision-making and/or the treatment of a medical eye problem. Medical Insurance Medical Insurance will pay for your eye care if your examination requires testing and medical decision-making because you have: Systemic health problems (diabetes, high blood pressure, thyroid, etc.) An eye disease (cataracts, glaucoma, diabetic retinopathy, allergic conjunctivitis, ocular surface disease, etc.) A medical condition that requires taking a high-risk medication (plaquenil, etc.). If you have a medical problem or we discover a medical eye problem during the exam, we are required to furnish a Medical-level eye examination that is determined by your Medical Insurance Carrier. The complexity of your medical condition and the level of medical decision-making required to treat the problem are factors used to determine the exam fee level and co-pay amount. We did not set these fees your Insurance carrier did. Also, depending on your medical problem, certain Supplemental Tests may be necessary. The fees for these Tests are usually paid by your Insurance Carrier but often they will also require you to pay an additional co-pay amount. Medical Insurance Carriers have very specific guidelines regarding every aspect of your medical eye care testing and documentation which they require us as a provider by signed contract to follow. Our office did not make these Insurance rules; they were made by the Insurance carriers. In the event we do not take your major medical or vision plan, we will provide you with an itemized statement that you can file with your carrier. Please sign one of the applicable lines below: I DO have insurance and I authorize RIZ EYE to file my vision plan and/or Medical insurance claims I DO NOT have insurancePatient’s Signature (or Guardian if minor)RIZ EYE CARE CONTACT POLICY CONTACT LENS POLICY Advancements in contact lens technology offer the potential of successful contact lens wear to most of our patients. A contact lens is a medical device in contact with the tissues of your 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. Since follow up care is essential, it is your responsibility to keep all appointment and follow all lens care instructions. THE COMPREHENSIVE EYE EXAM Before a patient can be fit with contact lenses, a complete medical and refractive eye examination is necessary. This exam is critical to assure the good health of your eyes and to rule out the possibility of any unsuspected, underlying condition that may prevent contact lens use. CONTACT LENS EVALUATION & MANAGEMENT The goal of contact lens fitting is to find the most appropriate contact lens for each patient’s optimal vision and comfort. An enormous variety of types, materials, sizes and colors are offered. We are committed to taking the time and effort to fit your contact lenses properly. Although many patients will need only one fitting session, sometimes this process requires several appointments. In our experience, the extra time, effort and patience are well merited by both your ultimate satisfaction and the health of your eyes. All patients being fit into contacts for the first time must go through the fitting process. We will not finalize the contact lens prescription until both the patient and the doctor are satisfied with the fit and visual acuity of the contact lens. We will provide one set of trial lens. CONTACT LENS TRAINING SESSION The patient will be provided with personalized instruction concerning the safe care and usage of contact lenses. Upon completion of successful insertion and removal, the patient may begin wearing the contact lenses and we will schedule the first follow-up appointment. FOLLOW-UP APPOINTMENTS Follow-up appointments are necessary to assure several things: The contact lenses are fitting and moving well The prescription is providing the best possible vision The eyes are remaining healthy There are no problems with insertion or removal The patient understands and complies with the recommended wearing schedule After the first two follow/ups visit there will be a charge depending on fit level. Two follow up visits are given as a courtesy to insure patients satisfaction beyond two follow up visits fitting fees will apply. ANNUAL CONTACT LENS CHECK By law, a contact lens prescription is valid for only one year. All patients are required to come in for an annual contact lens exam. This is necessary to assure that the patient’s eyes are healthy and the contact lenses are still fitting well. Contact lens prescriptions cannot be renewed without an annual exam. If we are seeing you for the first time, and you have had a contact lens prescription from another office, the doctor will use his/her judgment to use the prescription from another office for the fitting and prescription of the contacts. CONTACT LENS FEE POLICY The fitting fee, which includes 2 follow-up visits within the first 30 days, is determined by the type of lenses prescribed, the difficulty of the fit, and whether or not the patient is a first-time contact lens wearer. THIS FEE IS NON REFUNDABLE AND DUE AT THE TIME OF SERVICE. If an initial fit needs to be changed, you will be charged the difference in the fitting fees between the original fit cost and the final fit cost. The fitting fee includes: The contact lens fitting A visit is required Training sessions 2 Follow-up visits within 30 days- After 1 month the fitting fee and a Refraction fee will be applied if visit is required. Diagnostic lenses (one trial pair) The fitting fee does not include: Contact lenses (Costs will vary depending on type of lens prescribed) The comprehensive eye exam Medical visits not directly related to contact lens wear Annual contact lens exam: It is our policy that all patients that are currently wearing contact lenses be seen every year for a contact lens examination. PAYMENT Fees for the comprehensive exam, contact lens fitting, or annual contact lens checks are due at the time of service. REFUNDS There will be NO refund of the exam, fitting, or annual contact lens check fees! I have read and understand the Contact Lens Policy, the Contact Lens Fee Policy, and the Contact Lens Care Guide. All of my questions have been answered and I have received copies of the above information. I understand that my compliance with the Contact Lens Care Guide is of the utmost importance in the health of my eye.Patient/Guardian Signature* Medical photography may be taken at the time of your visit using a phone or iPad assigned to our office. The photographs taken are used strictly for diagnostic purposes and will be placed in your medical record. Refusal to consent to photographs will not affect the medical care you receive but could affect medical decisions making. If you have any questions please contact our office. You may be scheduled with one of our highly qualified Optometric Assistants. All screening and tests are evaluated by our state-licensed Optometrist who will assess your eye health and create your prescription. If you wish to speak with our state-licensed Optometrist we offer tele-health visits before you leave the office. Riz Eye Care has given notice regarding tele-health Services, including risks and benefits of being treated via tele-health, and how to receive follow up care. By signing I acknowledge. Patient/Guardian Signature* By clicking SUBMIT I confirm I have read and understood all policies of Riz Eye Care, and give consent to treatment. For more information visit www.rizeye.com
