Healthcare Vision Form

HEALTHCARE VISION FORM

Patient Information

Patient Name:

Date of Birth: Gender: Male Female Other

Primary Phone: Email:

Relationship: Phone:

Insurance Information

Policy / ID Number: Group Number:

Vision History & Presenting Complaint

Last eye examination: Do you wear spectacles? Yes No

Contact lens use: Yes No If yes, type:

Medical History

Examination Consent & Authorizations

I, the undersigned patient or legal guardian, authorize the practitioner and clinic staff to perform a comprehensive eye and vision examination, including but not limited to refraction, intraocular pressure measurement, dilation of pupils, retinal photography, visual field screening, and contact lens fitting as clinically indicated. I understand that findings will be recorded in my medical record and used for diagnosis and treatment.

I acknowledge that pupil dilation may cause temporary blurred vision and light sensitivity, and that rare complications may occur. I have had the opportunity to ask questions regarding the nature, purpose, risks, benefits, and alternatives to the proposed procedures and understand I may refuse or withdraw consent at any time prior to the procedure without penalty.

Assignment of Benefits and Financial Responsibility: I authorize payment of insurance benefits to the provider for services rendered. I understand that I am responsible for charges not covered by my insurance, including co-payments, deductibles, and services denied as not medically necessary.

I authorize the release of my relevant medical and vision records to other healthcare providers and to my insurance carrier for treatment, payment, and healthcare operations as necessary for continuity of care. This authorization includes vision test results, images, and diagnostic findings.

Authorization expiration date:

HIPAA / Privacy Acknowledgment

I acknowledge that I have been offered a copy of the clinic's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I understand I may request restrictions on the use or disclosure of my health information, and that the clinic will accommodate reasonable requests in accordance with applicable law.

Release to Designated Individual(s): I authorize disclosure of my vision and medical information to the following person(s) if requested by the clinic:

Relationship: Phone:

Relationship: Phone:

Acknowledgment and Certification

I certify that the information provided on this form is accurate and complete to the best of my knowledge. I understand the nature of the proposed examination and associated procedures and consent to treatment as described. I authorize release of medical information for treatment, payment, and healthcare operations and assign insurance benefits where applicable.

I understand that I may be responsible for payment of services not covered by my insurance and I agree to cooperate with the clinic regarding claims and documentation needed for reimbursement.

By signing above, the signer certifies they have authority to consent on behalf of the patient if signing as guardian or legal representative and that a copy of this signed form is as valid as the original.

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