Eye Exam & Dilation Form

Retinal problems such as macular degeneration; glaucoma, retinal holes, retinal detachments and diabetic retinopathy can now be seen without dilation for most patients. All of our doctors recommend ALL patients have a digital image annually with the new state-of-the-art scanning digital imaging system. Early detection is crucial!

The contact lens evaluation is an additional $55-85 fee to the yearly comprehensive eye exam, which includes a glasses prescription. The evaluation includes all necessary follow ups, trial contact lenses and sample solution within the first 60 days. After the first 60 days, there will be a $30 fee for each additional visit. Contact lens evaluation fees are non-refundable.

The evaluation consists of determining the proper lens type and fit based on the curvature of your eyes, determination of correct contact lens prescription, as well as checking the clarity of vision and fit of the lens. Like glasses prescriptions, contact lens prescriptions need to be updated yearly. Many times, your contact lens prescription will be different than your glasses prescription. Additionally, and most importantly, you will be assessed for any health issues associated with contact lens wear.

I understand that I have certain rights to privacy regarding my protected Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

• treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
• Obtaining payment from third party payers (i.e. my insurance company)
• The day to day healthcare operation of your practice

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed, but that you are not required to agree to these requested restrictions. I understand that I may revoke this consent, in writing, at anytime. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.