Established Patient Form Step 1 of 5 20% Name(Required)as it appears on your insuranceWhat name do you prefer to be called?Date of Birth(Required) MM slash DD slash YYYY Home Phone(Required)Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell PhoneEmail(Required) Don't worry we won't send you any advertisingWhat insurance are you expecting to use for your exam?(Required)VSPEyeMedMedicareNo InsuranceSomething ElseWe pride ourselves on providing our patients with the highest possible standards of care. Our doctors require a full view of your retina every year or high-risk patients, and every other year for patients determined to be of low risk. They can obtain this view with traditional dilation and eye drops, or retinal imaging (photography). Our doctors prefer the photo as it offers a superior view of the retina, but allow patients to choose:(Required) I elect the Optos Retinal Photo and I understand that $39 will be due today I elect to receive traditional dilation. I understand I will have eye drops instilled for me, my exam may take up to an hour longer, and I will be light sensitive, and have blurred near vision for several hours afterwards — No Extra Charge Elective Contact Lens Evaluation(Required)Learn more about our Elective Contact Lens Evaluation Here. The contact lens evaluation is an additional component to the comprehensive exam. The contact lens evaluation is a service that may not be covered by your insurance. The service fee for most lens prescriptions ranges from $60-$165. This fee includes trial lenses, additional diagnostic testing, follow up appointments, and a valid contact lens prescription. Custom fit evaluation fees will be determined by your provider based on the complexity of your prescription. Contact lenses are a Class 2 medical device that require an evaluation as determined by your doctor. Choose 1: I want to wear contact lenses & I consent to a contact lens evaluation as part of my exam today and I Will be responsible for any fees not covered by mv insurance today. I am declining a contact lens evaluation today. By doing so, I understand I will NOT have a valid prescription on file, and I have up to 60 days after my comprehensive exam to return for a contact lens evaluation. Eyeglass Rule (2024)(Required)In order ensure a competitive market, you the consumer have the right to purchase your eyewear from any vendor you choose. A copy Of your eyeglass prescription is made available to you via your online patient portal immediately following your exam. Should you require an additional paper copy of your prescription. please inform a staff member and one will be provided to you. Any measurements associated with the fabrication of eyewear (such as pupillary measurements) are not included in your prescription. I agree Refraction(Required)A refraction (92015) is typically used to obtain a glasses prescription, but is sometimes used by doctors as a diagnostic test. The fee for this test is $45 and is a non-covered service by Medicare and most major medical insurance plans. In the event a refraction is done, and we are not expecting your insurance to cover it, this fee is collected at the time of service. I agree Insurance Authorization(Required)I authorize Huffman Family Eye Care to bill services on mv behalf. I authorize my insurance company to directly pay Huffman Family Eye Care. I understand my insurance coverage is a contract between my insurance provider and myself and it is my responsibility to be aware of any exclusion, network requirements, benefits, copayments and deductibles as outlined in my insurance plan. I agreeAgreement to Pay for Services Rendered(Required)I ensure that I am responsible for the payment of all services rendered on my behalf, or on behalf of my dependents. Payment is due at the time of service. If a claim is submitted to my insurance, the balance will be due upon receipt of statement. I agreeHIPAA(Required) I acknowledge that I have received a copy of Huffman Family Eve Care's notice of privacy practices. Name of PatientIf under 18: Guarantor/Legal Guardian:RelationshipSignature Δ
