Return Patient Information Form

Review of Systems

Do you currently, or have you ever had any recurring issues in the following areas?

Social History

PATIENT RESPONSIBILITY and VISON VS MEDICAL INSURANCE

-Individual’s Financial Responsibility

• I understand that I am financially responsible for my health/vision insurance deductible, coinsurance, or non-covered services.

• Co-payments are due at the time of service.

• If my plan requires a referral, I must obtain it before my visit.

• In the event that my insurance plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the costs of ALL services provided.

• If I am uninsured, I agree to pay for the medical services rendered at the time of service.

-Vision vs. Medical Insurance

Most people have both vision and medical insurance. They are very different in the terms of the services they cover and it’s important to understand those differences. Vision coverage is mainly designed to determine a prescription for glasses, help pay for glasses or contacts, and to screen for medical conditions. It is not designed to be used for medical conditions, diagnostic or screening tests, or treatment plans. Some medical plans have a vision benefit.

When a medical diagnosis or condition is present (such as diabetes, high blood pressure, etc.) or an eye disease (such as infections, dry eye, allergies, cataracts, etc.) it is necessary to file the claim for your visit to your medical plan, and the co-pays, co-insurance, non-covered services, and deductibles apply. Vision insurance does not cover medical eye problems. Our office does not make the rules; they are defined by insurance carriers and we are required to follow them.

In most cases, it is difficult to know prior to examination which type of insurance will apply or with whom our office will be able to file a claim for you. We make every effort to determine as much information for you in advance.

Insurance Authorization for Assignment of Benefits and Acknowledgement of the Above Terms

- "I hereby authorize and direct payment of my insurance benefits to Corridor Family Eye Care on my behalf for any services provided to me by the office."

- "I understand the paragraphs above and authorize Corridor Family Eyecare to file a claim on my behalf and I understand that I am responsible for any co-pays, co-insurance, or deductible not yet met."

Please read the following:

During a comprehensive eye exam, our doctors need to evaluate the overall health of your eye. With OptomapⓇ Retinal Exam, we can screen for retinal complications including Macular Degeneration, Glaucoma, and retinal holes or detachments.

This screening procedure can also detect systemic problems unrelated to the eye that may show signs in the retina such as Diabetes, Hypertension, Cancer/Tumors, autoimmune disorders, and others, earlier than possible with traditional methods.

The OptomapⓇ Retinal Exam;

• Is as fast as taking a picture.

• DOES NOT REQUIRE DILATING DROPS. You may not need to be dilated today, potentially eliminating a 30-minute wait and avoiding side effects such as blurry vision and light sensitivity.

• is saved in your file, enabling our doctor to make important comparisons during your annual eye exam.

There will be a $34.00 charge for the OptomapⓇ Retinal Exam.

To opt out, simply skip this portion.

HIPAA

Link for HIPAA https://corridorfamilyeyecare.com/wp-content/uploads/2018/08/HIPPA-Privacy-Form.pdf

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

IMPORTANT-

Beginning 1/1/2026, our office will be charging a $25 fee for appointments canceled within 24 hours, and appointments which are missed without notification (No-Call-No-Show). We appreciate your understanding for our new change in policy. If you have any questions, please contact our office by Text or email. We look forward to seeing you for your appointment!