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Available Forms

Consent to Treatment

CONSENT TO TREATMENT: allows us to use and disclose your health information to carry out treatment, payment activities, and health care operations. Dilation may be deemed necessary. *If you are diabetic, you will be dilated to meet insurance health requirements. Dilation may temporarily impair near vision and increase light sensitivity.

Must be 18 yr or older

PRIVACY PRACTICE: HIPAA is a federal law that requires all medical records and health information be kept confidential. Our HIPAA policy is posted and describes our privacy practices. The Notice of Privacy Practice provides in detail the uses and disclosures of my protected health information that may be made by Advanced Family Eye Care. Copies of our HIPAA Policy are available.

Must be 18 yrs or older

FINANCIAL POLICY: Payment is due at the time of service. Rendered services are nonrefundable. Any bill incurred regardless of insurance is billed to the responsible party. Accounts 90 days old are subject to collection fees. A service charge applies to returned checks. Payment by insurance is paid directly to Advanced Family Eye Care. I understand that my primary and/or secondary insurance will be billed for services and that all benefits quoted to me are not a guarantee of payment by my insurance company. Final determination can only be made when the claim is processed. If your health plan determines a service to be "not covered," you will be responsible for the complete charge. My signature below authorizes Advanced Family Eye Care to file claims with my insurance provider and to release any necessary information to process claims.

Must be 18 yrs or older

Minor Patients: The parent who brings the child for their visit is responsible for making payment on the exam date. It is the patient's responsibility to know and understand their insurance plan's coverage.

RESPONSIBLE PARTY: Insurance will at times pay differently than anticipated. In case of an under or over payment, please verify the responsible party for billing/and or refunds.

Enter full name

ATTENTION CONTACT LENS PATIENTS: Contact lenses are medical devices and require expert fitting and documentation regulated by the FDA. Contact lens professional fees can range from $65 to $150 annually, depending on the complexity of contact lens related services. Out of pocket expense will depend on vision insurance coverage

Please print your name if you or your child will be having a Contact lens exam.
Please mark if you want Optos imaging, which is a $39.00 charge.
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