Policy Forms

Step 1 of 9 - Patient Information Acknowledgement - Optic Gallery Sahara

Patient Information Acknowledgement

In the event that it becomes necessary for us to release your records to or request your records from another healthcare professional, I authorize Optic Gallery, Dr. Cheung or any of her associates to release and/or request these records. If applicable, I request that payment of authorized Medicare or other insurance be made either to me or on my behalf to Optic Gallery, Dr. Cheung or any of her associates for any services rendered to me. I authorize pertinent medical information about me to determine insurance benefits and billing to be released to the health care financing or other insurance agencies. I understand that should my financial account become delinquent, it will be sent to collections where I will be responsible for any collections fees, attorney fees, and court costs. I UNDERSTAND I AM RESPONSIBLE FOR ANY CHARGES NOT COVERED BY MY INSURANCE COMPANY. It is the policy of this office to require: 1) Payment in full or at least one-half before the order can be placed. 2) The balance of the fee must be paid at the time the order is dispensed. 3) All orders are final when placed.

Patient Information Acknowledgement Consent.(Required)

I agree and understand the Patient Information Acknowledgement.

Name

First Last

Your Email(Required)

Signature (Patient or Guardian)(Required)

Disclaimer: By typing your name here in this field, it will be an authorized signature

Date of Signature(Required)

MM slash DD slash YYYY

Record Retention Policy

We are informing you that our office will keep your records for 5 years from the date of this examination. If signing for a minor, please be aware that our office will only keep your child’s records for 5 years from the date of this examination.

Record Retention Policy Consent(Required)

I agree to the Record Retention Policy.

Name

First Last

Signature (Patient or Guardian)(Required)

Disclaimer: By typing your name here in this field, it will be an authorized signature

Date of Signature(Required)

MM slash DD slash YYYY

Notice of Privacy Practices Acknowledgement

Signing in this section signifies that you have received a copy of our Notice of Privacy Practices. In the course of providing service to you, we create, receive, and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for these services, and to conduct healthcare operations involving our offices. The Notice of Privacy Practices you have been given describes these uses and disclosures in detail.

Notice of Privacy Practice Acknowledgement Consent(Required)

I agree to and understand the Notice of Privacy Practices Acknowledgement.

Name

First Last

Signature (Patient or Guardian)(Required)

Disclaimer: By typing your name here in this field, it will be an authorized signature

Date of Signature(Required)

MM slash DD slash YYYY

iWellnessExam & Digital Retinal Photography

The iWellnessExam is a quick, non-invasive scan that allows our doctors to see beneath the surface of your retina. This unique technology combined with digital retinal photos can help our doctors detect vision threatening conditions and systemic diseases in their very early stages, when they are most treatable. Our doctors recommend these tests as a routine part of the comprehensive eye exam for all of our patients. They are a great alternative if you would prefer to not have your eyes dilated at this visit. The iWellnessExam and digital retinal photography are especially important if you or your family have a history of diabetes, high blood pressure, high cholesterol, headaches, cataracts, glaucoma, macular degeneration, or other eye conditions. These conditions can be monitored closer and more accurately with these tests. The cost of these procedures is $49. It is not routinely covered by insurance, but some plans do offer a discount of $10. Please ask our staff if you have any questions.
Please select one of the options below, indicating your choice for the iWellnessExam and digital retinal photography:

iWellnessExam & Digital Retinal Photography Consent(Required)

YES, I wish to have the iWellnessExam and retinal photography performed today.

NO, I do not wish to have the iWellnessExam and retinal photography performed today.

MAYBE, I have additional questions about the iWellnessExam and retinal photography.

Name

First Last

Signature (Patient or Guardian)(Required)

Disclaimer: By typing your name here in this field, it will be an authorized signature

Date of Signature(Required)

MM slash DD slash YYYY

Dilation of the Eye

This procedure allows the doctor to obtain a better view of the back of your eyes. It is recommended annually and is covered by all insurances. The dilating drops typically last 4 hours. During this time, you may find it difficult to focus at near, and less commonly at distance. You may be sensitive to light. You will be provided with post-dilation glasses. We strongly recommend caution when driving or operating equipment or machinery after dilation. If you feel you would be unable to drive or return to work, we can reschedule the dilation portion of your exam. Signing in this section signifies that you have been informed of the risks and benefits of dilation.

Dilation of the Eye Consent(Required)

I wish to have my eyes dilated today.

I do not wish to have my eyes dilated today and assume the responsibility of having an eye exam without dilation.

I wish to have the dilation exam scheduled for another day.

Name

First Last

Signature (Patient or Guardian)(Required)

Disclaimer: By typing your name here in this field, it will be an authorized signature

Date of Signature(Required)

MM slash DD slash YYYY

Late Policy

If you are 15 minutes late of your scheduled appointment time, your appointment will be re-scheduled and you have the option of being a walk-in.

Cancellation of Appointment(s)/No-Show Policy

Patients wanting to cancel an appointment are asked to call the office by a minimum of 4 hours prior to the appointment time. The charge for not cancelling within a 4 hour notice is $25.00, which will be charged to the patient/guarantor and is NOT payable by any insurance company. Patients who do not show up for their appointment without a call to cancel will be considered a NO SHOW. Patient who No-Show 3 or more times in a 12-month period may be dismissed from the practice and thus they will be denied any future appointments. All no-show fees MUST be paid prior to the next appointment in order to be seen.

Informed Consent/Agreement(Required)

I have been informed of and understand the late policy.

I have been informed of and understand the No-show/Late Cancellation Policy. I understand that a no-show or late cancellation will result in a $25.00 charge that is not covered by any insurance.

Name

First Last

Signature (Patient or Guardian)(Required)

Disclaimer: By typing your name here in this field, it will be an authorized signature

Date of Signature(Required)

MM slash DD slash YYYY

Financial Responsibility Policy

Payment for services provided by Optic Gallery is required at the time services are rendered. If we are contracted with your insurance we will bill your insurance as a courtesy to you. Understand it is ultimately your responsibility as the patient/guardian to know your insurance coverage. If you need further clarification than provided, contact your insurance directly. Although Optic Gallery contacts your insurance for benefits, be aware that benefits quoted is not a guarantee of benefits and/or payment. Information given to Optic Gallery is an estimate and further payment may be required after your claim has been processed. In the event your account becomes past due, your balance will accrue interest at the rate of 1.5% per month. An account becomes past due when it is not paid within 30 days from our 1st date of billing you. If you fail to pay your balance, make a satisfactory arrangement or we are unable to locate/notify you despite a reasonable effort, your balance will be turned over to our collection agency. If your balance is turned over to our collection agency a $25 fee will be assessed in addition to any accrued interest and your balance will continue to accrue interest at the rate mentioned.

Financial Responsibility Policy Consent(Required)

I understand and agree to the Financial Responsibility Policy stated above.

Name

First Last

Signature (Patient or Guardian)(Required)

Disclaimer: By typing your name here in this field, it will be an authorized signature

Date of Signature(Required)

MM slash DD slash YYYY

Frame Warranties

Frame warranties are manufacturers defect warranties only. Any replacement frames at no charge are at the discretion of the manufacturer and office staff. Loss and theft are not covered under the frame warranty. Any damage that is not caused by a defect in the frames parts and/or quality will not be covered for a replacement under warranty. This includes bite marks, scratches, distortion of the frame caused by being sat or stepped on, etc. ANY alterations made to the frame will result in the warranty becoming void, THIS INCLUDES ANY GLUE. Any frame replacements not covered under warranty will be at our usual and customary fees.

Frame Warranties Consent(Required)

I understand and agree to the Frame Warranties stated above.

Name

First Last

Signature (Patient or Guardian)(Required)

Disclaimer: By typing your name here in this field, it will be an authorized signature

Date of Signature(Required)

MM slash DD slash YYYY

Communications

Please select communication preference(Required)

I wish to receive appointment reminders or material pick up notifications via text or email.

I do not wish to receive appointment reminders or material pick up notifications via text or email.

Name

First Last

Signature (Patient or Guardian)(Required)

Disclaimer: By typing your name here in this field, it will be an authorized signature

Date of Signature(Required)

MM slash DD slash YYYY

Phone

This field is for validation purposes and should be left unchanged.