We learn about you and your insurance from the confidential information YOU PROVIDE to us. We are not agents of
your employer or insurance company. There is no master list of what plan you have or if and when your coverage
changes. We require your cooperation in providing accurate insurance information.
My signature below indicates my acceptance of the following:
I agree to and understand that certain ancillary tests may be performed by trained staff and/or externs. I hereby
acknowledge that Drs. Gubman and Silbert are certified Preceptors authorized by the New Jersey Dept. of Law and
HIPPA Notification – I have received a copy of the posted HIPAA – Notice of Privacy Practices
One Time Authorization for Signature on File – I authorize and request my health insurance company to pay directly on
my behalf for any/all eligible services rendered.
I understand that I am financially responsible for all services rendered and received by me or my dependents. If
my insurance provider denies payment or coverage, I will pay my bill for the services and materials that I
Our Scanning Retinal Imager uses low level red and green light to digitally map your retina without dilating eye drops and bright lights. The digital map can be viewed on a computer monitor and will be shown to you during your visit with the doctor. 92% of patients choose the retinal scan!
DESIGNED TO DETECT: Macular Degeneration, Diabetic Retinopathy, High Blood Pressure, Hypertensive Retinopathy, Retinal Freckles (Nevi), Diabetes, Retinal Scars, Retinal Detachment / Tears, Some types of Cancer, Retinal Bleeding, and Nearsighted Retinal Thinning.
BENEFITS TO EACH PATIENT: Complete Retinal examination No dilating drops Eye Disease Detection No waiting for drops to work (20-30min) Systemic Disease Detection No blurred vision for 4-6hrs Better Medical documentation (digital image) No light/sun sensitivity for 4-6hrs Return to work/school with normal vision No driving glare for 4-6hrs.
The additional fee for the Retinal Imager is only $39 (It is NOT covered by insurance or vision plans).
A Contact Lens Examination is necessary if you need a renewal of your Contact Lens Rx for ordering replacement lenses.
An Examination for contact lenses is NOT part of a regular eye examination.
There is a separate fee for contact lens examinations (usually ranging from $69-$129 depending on complexity)
In the course of providing service 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 our services, and to
conduct health care operations involving our office.
We have a comprehensive Notice of Privacy Practices that describes these uses and disclosures in detail. You
are free to refer to this Notice at any time before you sign this consent document. As described in our Notice of Privacy
Practices, the use and disclosure of your health information for treatment purposes not only includes care and services
provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive
follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes
of payment includes our submission of your health information to a billing agent or vendor for processing claims or
obtaining payment; our submission of claims to third-party payers or insurers for claims review, determination of benefits
and payment; our submission of your
health information to auditors hired by third-party payers and insurers, among other aspects of payment described in our
Notice of Privacy Practices. In order for us to service your account or to collect monies you may owe, The Eye and Sight
Center, and/or our agents may contact you by telephone at any telephone number associated with your account including
wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or
emails, using any email address you provide to us. Methods of contact may include using pre-recorded/artificial voice
messages and/or use of automatic dialing devices, as applicable. Our Notice of Privacy Practices will be updated whenever
our privacy practices change. You can get an updated copy here at the office or from our Web site.
When you sign this consent document, you signify that you agree that we can and will use and disclose your
health information to treat you, to obtain payment for our services, and to perform health care operations. You can revoke
this consent in writing at any time unless we have already treated you, sought payment for our services, or performed
health care operations in reliance upon our ability to use or disclose your health information in accordance with this
consent. We can decline to serve you if you elect not to sign this consent form.
You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment or health
care operations, but as described in our Notice of Privacy Practices, we are not obligated to agree to these suggested
restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how
to ask for a restriction.