Healthcare Eye Document

HEALTHCARE EYE DOCUMENT

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information

Medical & Ocular History

Primary reason for today's visit:

Have you ever been diagnosed with glaucoma? Yes No

Do you wear contact lenses? Yes No

Examination, Testing and Treatment Consent

I authorize physicians, optometrists, and qualified clinical staff to perform a comprehensive ocular examination, necessary diagnostic testing (including but not limited to visual acuity, refraction, intraocular pressure measurement, slit lamp biomicroscopy, and retinal imaging), and to provide treatment recommended as part of the examination. I understand that the scope of services will be explained to me and that I may ask questions prior to any procedure.

I certify that I have provided an accurate medical history and that failure to disclose medical conditions or medications may increase the risk of adverse outcomes. I understand that medicine and eye care do not guarantee a cure, and that complications can occur.

Pupillary Dilation and Diagnostic Imaging Consent

I consent to pupillary dilation when recommended. I understand dilation causes temporary blurred near vision and light sensitivity, may affect ability to drive, and may rarely precipitate acute angle closure in predisposed individuals. I will notify staff if I experience severe pain, nausea, or sudden visual changes after dilation.

I consent to retinal photography, optical coherence tomography (OCT), visual field testing, and other imaging as clinically indicated. I understand these tests aid diagnosis and management but may not detect every condition.

Authorization to Release Medical Information

I authorize the release of my ocular and medical records, including diagnostic images and reports, to the person(s) or organization(s) named below for the purpose indicated. I understand that information disclosed pursuant to this authorization may include sensitive health information.

This authorization will remain in effect until:

I understand that I may revoke this authorization at any time by submitting a written revocation, except to the extent that action has already been taken in reliance on this authorization. I understand that information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by privacy rules.

HIPAA Privacy Acknowledgment

I acknowledge that I have been offered a copy of the Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights regarding that information. I understand that I may request restrictions on certain uses and disclosures, and that such requests will be considered but are not binding unless accepted in writing.

Financial Responsibility & Certification

I accept financial responsibility for services rendered. I authorize release of information necessary to process claims and request payment of benefits to the provider. I certify that the information I have supplied is accurate and complete to the best of my knowledge. I understand I remain responsible for any charges not covered or paid by my insurance.

I understand that I may refuse any proposed treatment or procedure after risks, benefits, and alternatives have been explained to me. I have had the opportunity to ask questions and receive answers to my satisfaction.

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