Healthcare Vision Application

HEALTHCARE VISION APPLICATION

Patient Information

Patient Name:

Date of Birth:    Gender (select one): Female Male Other/Prefer not to say

Emergency Contact

Insurance Information

Vision Coverage Requested

Services requested (check all that apply): Routine eye exam Eyeglass lenses Frames Contact lenses Medical eye care (disease/injury)

Medical and Ocular History

Eye conditions (check all that apply): Glaucoma Cataract Macular degeneration Diabetic eye disease Amblyopia (lazy eye) Strabismus (eye turn) None of the above

Date of last eye exam:    Do you wear corrective lenses? Glasses Contacts

Consent and Authorization

By signing below, I authorize the performance of eye examinations and any medically necessary diagnostic procedures or minor treatments as determined by the examining clinician. I understand that the provider will explain recommended procedures, potential risks, and alternative treatments; I may withhold or withdraw consent at any time by providing written notice to the provider, subject to clinical necessity for safe care of ongoing services already rendered.

I authorize release of medical and billing information necessary to process claims to my insurance company and permit direct payment of benefits to the provider where applicable. I understand I remain financially responsible for charges not covered or paid by my insurer, including co-pays, deductibles, non-covered services, and services denied for lack of preauthorization when required by my plan.

I acknowledge receipt of the provider's privacy practices and consent to the use and disclosure of my protected health information for treatment, payment, and health care operations as described in that notice. This authorization includes release of records for claim adjudication and for review by medical consultants as necessary.

Authorization to release information and to bill my insurer shall remain in effect until the authorization expiration date specified below or until revoked in writing. Revocation will not affect disclosures already made in reliance on this authorization.

Authorization expiration date:

I authorize release of medical and billing information to the insurer and other care providers as necessary for claims processing.

I accept financial responsibility for services not covered or paid by insurance.

I acknowledge receipt of the provider's privacy practices and consent to use/disclosure of my health information for treatment, payment, and health care operations.

Certification

I certify that the information provided in this application is true and correct to the best of my knowledge. I understand that willful falsification of information may subject me to denial of coverage or reimbursement and may be subject to civil or criminal penalties under applicable law. I authorize verification of any information provided on this application for the purpose of determining benefits and coverage.

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