Notice Of Practice And Insurance Release Form printable pdf download

Notice Of Practice And Insurance Release Form

NOTICE OF PRACTICE AND INSURANCE RELEASE FORM

I have reviewed a copy of Clermont Family Eyecare’s Notice of Privacy Practices. I

authorize the release of my medical records necessary to process this claim. I also

request payment of benefits to Clermont Family Eyecare for services received. If

the insurance does not cover or pay the optical, I will be responsible and pay for

services I received.

____________________________________

______________

PATIENT SIGNATURE

DATE

(or Parent/Guardian signature if patient is under 18)

***!!ATTENTION!!***

***You must read this section & make a selection before returning your

paperwork to the front desk***

To dilate your eyes, the doctor is going to put some medication in your eyes. The medication

will make your pupils big so that the doctor can examine the inside of your eyes for any

conditions like glaucoma, cataracts, and retinal diseases. The drops will take 10 – 15 minutes

to take effect. Side effects include dilated pupil, blurry vision up close, and sensitivity to bright

lights which can last at least 3-4 hours, and in rare cases up to 24 hours. The importance of

the dilation is that without it, the doctor cannot completely check the health of the back of

the eyes.

PLEASE CHECK ONE OF THE FOLLOWING:

___ I do want to have my eyes dilated today.

___ I would like to reschedule my dilation for another day.

___I do not want my eyes dilated

Notice Of Practice And Insurance Release Form