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Dilation Form

Retinal problems such as macular degeneration; glaucoma, retinal holes, retinal detachments and diabetic retinopathy can now be seenwithoutdilation formostpatients.Early detection is crucial!
Please Select 1 Option:
Dilated Exam VS OptoMap Exam
1. Blurred near vision/light sensitive 4-8 hours. 1. No blurred vision/Light sensitivity.
2. Longer office visit (approx. 30 min) 2. Retinal image becomes permanent part of your medical record and you can view with the doctor
3. No permanent visual record of the retina in your medical history. 3. Doctor preferred and completely safe!

CONTACT LENS AGREEMENT

The contact lens evaluation is an additional $55-85 fee to the yearly comprehensive eye exam. The evaluation includes up to three follow ups and a set of trial lenses. Additional trials are $20 per set.After the first 60 days, there will be a $35 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 prescription, clarity, and any associated health issues.Like glasses prescriptions, contact lens prescriptions need to be updated YEARLY.Your contact lens prescription may differ from your glasses prescription.

By signing below, you are agreeing to the terms and conditions stated above.

HIPAA PRIVACY POLICY PATIENT CONSENT FORM

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.

I have read and understand my rights under HIPAA Policy
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