Company has taken all precautions recommended by the Centers for Disease Control and Prevention for business who are continuing to provide services to customers during the COVID-19 crisis. This includes the Interim Guidance for Businesses and Employers to Plan and Respond to Coronavirus Disease 2019 (COVID-19) and Cleaning and Disinfecting Facilities. (https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-business-response.html) Additionally, Company has been screening our employees before every work shift to ensure that no employee is suffering any of the known symptoms of COVID-19, including running a fever, having a dry cough, or experiencing shortness of breath. However, it is also known that those without symptoms may still be capable of infecting others as an asymptomatic individual with COVID-19 and despite precautions taken the virus may still be present and capable of infecting individuals.
Knowing this information, I voluntarily elect to continue with my scheduled appointment with Company and I hereby agree to accept and assume any and all risks of personal injury or death.
Waiver of Liability and Indemnification
In consideration for being treated by Company, on behalf of myself, my personal representatives, heirs, next of kin, successors and assigns, I forever:
waive, release, and discharge Company, its agencies, officers, and employees from any and all negligence and liability for my death, disability, personal injury, or claims of any nature which may hereafter accrue to me, and my estate as a direct or indirect result of my participation in the above referenced appointment; and defend, indemnify, and hold harmless Company, its agencies, officers and employees, from any and all claims of any nature, including all costs, expenses, and attorney's fees, which may in any manner result from or arise out of this agreement, except for claims resulting from or arising out of Company willful or intentional negligence.
This release, indemnification, and waiver shall be construed broadly to provide a release, indemnification, and waiver to the maximum extent permissible under applicable law.
I, the undersigned, affirm that I am at least 18 years of age and am freely signing this agreement or that I am signing on behalf of a minor child that I have the legal authority to sign such agreements on behalf of. I have read this form and fully understand that by signing this form I am giving up legal rights and/or remedies which may otherwise be available to me regarding any losses I may sustain as a result of my appointment. I agree that if any portion is held invalid, the remainder will continue in full legal force and effect.
Optomap
We are proud to introduce the latest in retinal imaging, the Optomap. It is painless, quick
and the doctor’s preferred method of monitoring the health of your eye. This instrument will
enhance our ability to detect and monitor retinal defects associated with common systemic
diseases such as hypertension, diabetes, high cholesterol, and thyroid problems. Through this
digital imaging of the retina, we can observe early changes in the eye relating to glaucoma,
cataracts, and macular degeneration. Optomap can detect debilitating or potentially fatal
disorders that can be present in the retina.
This technology can be used without dilation, and will be a permanent part of your medical
records. There are no side effects with this test.
Medical vs. Vision insurance explanation
Most people have vision insurance and medical insurance. They are very different in terms of the
services they cover and it is important for our patients to understand those differences. Vision coverage (VSP,
Spectera, EyeMed, Davis, ect….) is mainly designed to determine a prescription for glasses and is not
equipped to deal with complex medical conditions and/or diagnosis. It does allow for screenings of
conditions, but once they are determined, then medical insurance is filed on those services. When a medical
condition is present (such as diabetes, cataracts, dry eye, floaters, etc.) it is necessary to file the visit with your
major medical carrier (BCBS, Aetna, UHC, Cigna, etc.) and the co-pays for that insurance will apply. Insurance
carriers set these rules and our office is required to follow them. In most cases, there is no way to know prior
to the examination which type of insurance our office will be able to file for you.
1. If you have ANY problems or complaints that MAY be attributable to a medical condition which requires a
more in-depth investigation and additional medical decision-making to rule out any underlying eye
disease, we will accordingly bill your MEDICAL insurance, NOT you vision plan. These include, but are not
limited to:
• New or sudden blurry vision
• Flashes or floaters
• Dry or itchy eyes
• Eyestrain or double vision
• Eye pain or redness
• Headaches
• Loss of vision
2. There are a variety of systemic conditions that can profoundly and permanently affect a patient’s vision
that require a more in-depth investigation, which may include additional testing, follow up visits, and
reports to your primary care physician. This type of examination is NOT covered under “vision” plans,
and we will bill your MEDICAL insurance, NOT your vision plan. These include, but are not limited to:
• Diabetes
• Hypertension
• Thyroid disease
• Lupus or autoimmune disease
• Diseases resulting in use of high risk
medications like Placquenil
3. If you have previously been diagnosed by another eye doctor for any eye issues that require medical
decision-making, treatment or management, we will bill your MEDICAL insurance, NOT your vision plan.
These include, but are not limited to:
• Cataracts
• Amblyopic/lazy eye
• Glaucoma/previous diagnosis of high eye
pressure
• Macular or retinal disease
• History of eye surgery
We make every effort to be on every major carrier for your convenience and we will file those claims for
you. In the event that we do not take you insurance we will provide you with an itemized receipt so that you
may file with your carrier for reimbursement. If you have any question, please let us know