Healthcare Optomap Form

HEALTHCARE OPTOMAP CONSENT AND AUTHORIZATION

Patient Information

Date of Birth:    Gender:    Phone:

Insurance / Billing

Policy Number:    Group Number:

Medical History

Are you pregnant or breastfeeding? Yes

Procedure Description — Optomap Retinal Imaging

Optomap retinal imaging is a non-invasive, ultra-widefield photographic capture of the retina using specialized imaging equipment. The procedure involves focusing a low-intensity light into the eye while the device records retinal structure. Images assist the clinician in documenting retinal health, diagnosing pathology, and monitoring progression of disease.

Benefits: Optomap imaging facilitates early detection of retinal conditions, provides a permanent record for comparison over time, and may reduce the need for dilation on some patients. Limitations: Optomap images do not replace a comprehensive clinical examination and may not visualize all peripheral pathology in every case.

Risks, Alternatives and Patient Acknowledgement

I acknowledge that the risks associated with optomap imaging are minimal. Possible discomforts include brief light sensitivity, transient afterimages, and rare headache. There is a minimal risk of an allergic reaction to any drops applied if pupil dilation is performed. Alternative options include standard fundus photography, dilated examination without imaging, or no imaging.

I understand that the clinician recommends optomap imaging to assist in diagnosis and treatment planning. I have had the opportunity to ask questions and have received answers to my satisfaction.

Patient confirms the following (check each that applies):
I consent to optomap retinal imaging as described above.
I consent to pharmacologic pupil dilation if clinically necessary or requested by the clinician.
I acknowledge the benefits and limitations described and understand results cannot be guaranteed.

Use, Storage and Release of Images

I authorize the clinic to create, store and maintain digital optomap images in my medical record for diagnostic and treatment purposes. I understand images will be retained in accordance with standard medical record retention policies and may be used by the treating clinicians for continuity of care.

Release to other healthcare providers: I authorize the release of optomap images and associated findings to other healthcare providers involved in my care as necessary to coordinate treatment.

For educational or research use that does not identify me personally, I: Consent to limited use of de-identified images for education/research    Do not consent

Financial Responsibility

I understand that optomap imaging services may be billed to my insurance. I am ultimately responsible for any co-payments, deductibles, or non-covered charges. If my insurer denies payment, I agree to be responsible for the charge for the imaging performed.

Authorization and Expiration

By signing below, I authorize the performance of optomap retinal imaging and the uses and disclosures described herein. I understand I may revoke this authorization in writing at any time, except to the extent that actions have already been taken in reliance on the authorization. Revocation will not affect disclosures already made under this authorization.

Acknowledgment of Privacy Practices

I acknowledge that I have been offered or received the clinic's notice of privacy practices describing how my protected health information may be used and disclosed. I understand that I may request additional restrictions on the use or disclosure of my health information, and such requests must be submitted in writing.

Acknowledgment: I acknowledge receipt of the notice of privacy practices.

Additional Patient Statements

Sign Now