Bella Vista Eyecare Associates Registration Form

  • Acknowledgement of Notice of Privacy Practices

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  • If you are signing as a personal representative of the patient, please indicate your relationship.

  • Financial Policies and Patient Responsibility

    Bella Vista Eyecare Associates, PA does its best to accurately obtain your coverage and charge you in accordance to you insurance benefits. While we will do everything we can to keep you informed of covered vs. non-covered services (as quoted by your insurance company), final determination of coverage and payment is not made until our insurance claim is reviewed by your insurance company. By signing below, you understand that payment collected today is based on a quote from your insurance company and is not a guarantee of benefits. In cases where professional goods and services are not covered (therefore, denied) by your insurance company, it will be the patient's responsibility to pay for these services in full. Claims not paid due to errant or undisclosed insurance information provided by the patient will be the responsibility of the patient as well. If we are not on your insurance plan, we require full payment for all services and products at the time they are rendered, but will provide you with and itemized receipt that you may submit to you insurance plan for potential reimbursement. I have read and understand the financial policy of Bella Vista Eyecare Associates and I do accept financial responsibility.
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  • Vision vs. Medical Insurance and Assignment of Insurance Benefits

    Vision insurance coverage is designed to cover routine eye services and to determine a glasses and/or contact lens prescription. When a medical condition or diagnosis is present, it may be necessary to file your examination with your medical insurance. Many times, we may not be aware of any medical diagnosis beforehand. These rules are often dictated by the insurance carriers themselves. Should this situation arise, we will do our best to inform you as to whether we will file your examination to your vision or medical insurance. In either case, the patient is responsible for any financial responsibility as dictated by their respective insurance company. I authorize the payment of my medical/vision benefits to Bella Vista Eyecare Associates. I authorize Bella Vista Eyecare Associates to release any information required to process any and all claims for reimbursement on my behalf. A copy of this authorization may be used in place of the original.
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  • Minor Consent

    By law, any child under 18 years of age cannot be seen by a doctor without consent from a parent or legal guardian. If a child arrives with someone other than a parent or legal guardian, we must have written permission from the parent or legal guardian that this person has been appointed by you to act on your behalf.
  • Eye Health Exam Procedures

  • Retinal Photography Screening

    This procedure is a high resolution digital screening photograph of your retina which will help Dr. Eickhoff document, review, and compare your retina each year to catch any potential problems at early stages. It is also a great way to document a baseline of your child's eyes at a young age for future comparison. Retinal Photography Screening helps with the detection of: -Macular Degeneration -Glaucoma -Retinal Hemorrhages -Diabetes -High Blood Pressure -Vascular Disease Your insurance company will only pay for retinal photography AFTER eye disease is discovered. In order to perform a screening test for early detection, there will be an out of pocket cost of $29.
  • Dilated Fundus Examination

    The purpose of dilating your pupils is to perform a more thorough examination of the health of your retina by viewing the iris, or colored area of your eye. This allows Dr. Eickhoff to access the peripheral retina, which would otherwise not be visible. Secondly, dilating drops can relax your focusing muscles and in certain cases detect hidden vision problems, which would not have otherwise been detected. You may experience some mild side effects after dilation including blurry vision, light sensitivity, nausea, dry mouth, and burning upon instillation. These effects can last up to 6 hours. If you should experience the above symptoms for longer than 6 hours call or return to our office immediately. Disposable sunglasses will be provided for our comfort and safety. Dr. Eickhoff recommends this procedure for: -ALL first time patients -Higher Prescriptions -Over 55 years of age -Anyone experiencing Flashes of Light, Floaters or Headaches -Diabetes, Hypertension, or other Systemic Disease -Cataracts, Glaucoma, Macular Degeneration, or Retinal Conditions -Children under 12 years of age This procedure is included in a Comprehensive Eye Exam and therefore will be performed at no additional cost to you.
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  • Contact Lens Exam Agreement

  • What is a contact lens exam?

    A contact lens exam is an additional, separate portion of a comprehensive eye examination. As contact lenses are most often an elective addition to a glasses prescription, most insurance companies do not cover contact lens evaluations. Any contact lens exam fees that are not covered by insurance will be the responsibility of the patient. At Bella Vista Eyecare Associates, our contact lens services range from $60 to $170 depending on the type of contact lens being fit. Contact lens evaluations do not include the actual supply of contact lenses. Contact lens prescriptions expire after 1 year. -Insertion/removal training for first time wearers fee $40.00
  • What is included in a contact lens exam?

    -Determination of candidacy for contact lens wear -Determination of contact lens prescription based on glasses prescription -Evaluation of tear film and cornea -Evaluation of contacts on the eye -Contact lens trials needed to determine of final prescription -Trial size contact lens solution and case -Any contact lens related follow-ups for a period of 6 months. Any contact lens follow-up after 6 months will incur a $60 fee. I have read and agree to the terms of the Contact Lens Fit Agreement.
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