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New Dilation Contact Consent

  • Dilation*
    Pupil Dilation is a recommended part of our COMPLETE eye examination for ALL ages. It allows the doctor to better examine the retina for retinal detachments, holes, tumors, leaking blood vessels, and other retinal problems. Pupil dilation is HIGHLY recommended and suggested for ALL of our patients; however, dilation is especially important for our patients
    • Over 40 years of age and Children
    • With high eyeglasses prescriptions
    • With history of head or eye injuries
    • With Diabetes, Hypertension, or Heart disease
    • Who are taking certain medications
    The most common side effect of the eye drops used in the dilation process are light sensitivity and blurred vision within arm’s length. Distance vision is usually not significantly affected, so you should be able to drive at your discretion. If you don’t have sunglasses with you, they are provided. The effects of pupil dilation last from 3-6 hours.
  • Contacts
    If you are a contact lens wearer or want to try contacts for the first time; there will be a contact lens fitting/evaluation fee that is required on the date of service. This fee also applies to patients who have previously worn contacts. It includes a pair of trial lenses until ordered contacts are received and also a 60 day follow-up period if needed. A prescription will not be released until after your follow-up exam and all fitting fees have been paid.
  • Notice of Privacy Practices
    THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED. YOU MAY ALSO HAVE ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.
    We also require by law to maintain the privacy of your health information and to provide you with this notice of our legal duties and private practices with respect to your medical information. We are required by law to abide by the terms of this notice.
    I have been presented with the Notice of Privacy Policy of NORWOOD FAMILY EYE CARE, LLC (the provider) and have been offered a copy of such policy for my records
  • PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE
    • I authorize the release of any medical or any other information necessary to process my claims. I also request payment of government benefits either to myself or to the party who accepts assignment: NORWOOD FAMILY EYECARE, LLC.
    • I authorize payment of medical/vision benefits to NORWOOD FAMILY EYE CARE, LLC for services rendered. I agree to be financially responsible for ANY BALANCE NOT PAID by insurance plan.
    I certify that the information given by myself, in applying for insurance and/or Medicare payment is true and correct. I authorize my doctor to act as my agent in helping me obtain payment of my insurance and/or Medicare benefits, and I authorize payment of these benefits directly to Norwood Family Eye Care, LLC on my behalf for any services and materials furnished. I authorize any holder of medical information about me to release to centers of Medicaid and Medicare Services and its agents any information needed to determine these benefits payable to related services. If I have other health insurance coverage (as indicated in item 9 of the CMS-1500 claim form or electronically submitted claim), my signature authorizes release of the above medical information to the insurer or agency shown, and authorizes my doctor to act as my agent.
  • Date Format: MM slash DD slash YYYY
  • PLEASE NOTE
    • Professional fees for exam are NOT refundable; NO EXCEPTIONS
    • Glasses prescription rechecks are available at no charge for 45 days from original exam by original doctor. Fees apply after 45 days or for a second opinion. Contact lens evaluation period is 60 days from original exam.
    • Problem eyes not related to contact lens fit are considered a separate office visit.
    • Routine vision exams (glasses/contacts) and Medical eye exams (Diabetic, eyes red, burn, itch, dry etc.) CAN NOT be performed on same day. Medical eye problems are not covered by your vision plan. You must use your medical insurance for medical eye exams.
    • Insurance cards must be presented at time of exam. If you find that you have insurance coverage at a later date, you will be given an itemized receipt to present to your insurance company for reimbursement. No back authorizations will be done.