Routine Vs Medical Exams Form printable pdf download

Routine Vs Medical Exams Form

Routine vs. Medical Exams

For insurance purposes, eye examinations are divided into two categories:

Routine Vision Exams

These are vision exams for people who have no eye disease or symptoms. Your eyes will be examined

for any needed correction (eyeglasses or contact lenses). If your doctor sees indicators of eye disease,

further testing of a medical nature may be needed through your medical insurance.

Examples of Routine Vision Insurances are Vision Service Plan, Davis Vision, EyeMed, and Blue Vision.

Medical Eye Exams

This is a comprehensive examination for the diagnosis and treatment of diseases performed by a

physician/surgeon. Some examples of conditions that are evaluated during a medical eye exam are

diabetic retinopathy, cataracts, glaucoma, and dry eyes.

Please choose one of the following:

□

I choose to use my Routine Vision Coverage. I wish to be evaluated for any needed

correction of my vision in the form of contacts or eyeglasses. I do not have any underlying

eye diseases or symptoms to be evaluated. I understand that I may need further evaluation

or testing of a medical nature if the doctor finds signs of eye disease. This would require the

use of my medical insurance.

□

I choose to use my Medical Insurance Coverage. I have an underlying eye disease or

symptoms of an underlying eye disease that I wish to have evaluated.

Patient Signature:__________________________________________ Date:_______________

Routine Vs Medical Exams Form