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Envision Boulder Patient Registration Formadmin2021-01-13T20:40:49+00:00

  • ENVISION BOULDER: WELCOME TO OUR OFFICE


  • MEDICAL HISTORY: PLEASE CHECK ONLY BOXES THAT APPLY. UNCHECKED BOXES WILL MEAN “NO.

  • PERSONAL EYE HISTORY

    CONDITIONS

  • SURGERIES

  • PERSONAL MEDICAL HISTORY

    CONDITIONS

  • SOCIAL HISTORY

  • FAMILY HISTORY

    OCULAR CONDITIONS

  • MEDICATIONS

  • Please add medication and purpose, if any
  • MEDICATION ALLERGIES

  • MM slash DD slash YYYY
  • Please enter a number from 5 to 24.
  • Privacy Policy

  • In the course of providing services to you we create, receive, and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for services, and to conduct healthcare operations involving our office. The Privacy Policy describes these uses and disclosures in detail. 

    I acknowledge that I have been offered and/or received a copy of the Privacy Policy from Envision Boulder. 

  • Please write your name to sign.
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  • Financial Policy

  • Insurance for Eye Care – Medical and Vision Plans 

    There are many types of health and vision insurance that can help pay for your eye care services and products; however, our practice only accepts Vision Service Plan, Colorado health First and Medicare for routine eye exams. 

    Vision care plans only cover routine vision exams including refraction (testing for prescriptions) and a basic eye health screening. They do NOT cover diagnoses, management, or treatment of eye disease. 

    Medical insurance must be used for a patient’s eye care visit when the doctor determines a medical diagnosis as the cause of a patient’s reason for their visit. Examples include blurred vision, eye pain, eye infections, foreign body removal, sudden onset of flashes and floaters, etc. It also covers visits and additional testing to monitor progressive eye conditions and to determine if a patient’s general health issues or medications may be affecting their eyes. Refraction is typically NOT covered by medical insurance.

    If you have both types of insurance plans it may be necessary for us to bill some services to your medical insurance and some services to your vision insurance. Insurance carriers set these rules and our office is obligated to follow them. We will use coordination of benefits to do this properly and to minimize your out-of-pocket expenses. Co-pays, deductibles, and non-covered services are the responsibility of the patient. 

    For patients without insurance or for whom our office is out-of-network we will provide an itemized receipt that can be filed to the carrier or submitted to HSA for reimbursement. 

    I have read and agree to this policy and authorize Envision Boulder to file my insurance by the above guidelines.


  • Please write your name to sign.
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