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Eye Center of Houston

  • Patient Information

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  • Insurance

  • Visual and Medical History

  • All insurances must be presented at the time of service. Professional fees are non-refundable and non-negotiable. Payment must be collected at time service is rendered. For insurance patients, please be aware that you are fully responsible for the services not covered by your insurance plan.

  • YOU MUST READ AND SIGN THIS SECTION

  • Visual Field Screening: This screening checks for visual field defects, both in central and peripheral vision areas using the latest technology. Visual fields screening can assist in early detection of glaucoma, optic nerve disease, visual related neurological diseases, and possible cause of headaches. The fee for this screening is $20.00.

  • Pupil Dilation: Dilation enlarges the size of the pupils and allows the doctor a more thorough examination of the retina. This helps to detect many medical conditions such as diabetes, glaucoma, cataracts, hypertensive changes, retinal holes and detachments, and melanomas (tumors). Dilation is strongly recommended for all patients. After being dilated, you may experience blurred near vision and light sensitivity that can last from 3-6 hours.

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  • HIPAA PRIVACY

    I understand that the Eye Center of Houston may use and disclose necessary personal health information (for example, my name, address, subscriber identification number, eye exam information, and/or type of products provided) to another party to permit to perform its administrative duties, provide me with eye care services and products, process my medical and/or vision benefit claims and communicate with me regarding medical/vision care services provided. I can be assured that this location does not sell my personal health information of any kind to a third party for such party's own use. I authorize to submit my medical/vision benefit claims to my plan sponsor or health plan to receive reimbursement directly for the medical/vision services and products that I have received.
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