Eyeworks of GA Patient Registration Forms

  • Patient Information Form

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  • Insurance Information

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  • Medical and Ocular History

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  • Patient/Family Medical History & Lifestyle Questions

  • PAYMENT POLICY FOR SERVICES AND MATERIALS

    If you are using insurance coverage for today’s visit, this is a contract between you and your insurance company. We will submit whatever we can to assist the process but if Eyeworks is not reimbursed in full, or paid by your insurance company, the balance is your responsibility. If there is any question of coverage, you may be required to pay at time of visit or post visit IF payment is received from your insurance company, you may be eligible for a refund or partial refund of payment. Payment for all services are due at time services are rendered. All sales on services and materials are FINAL. Deposits not paid in full or materials left for more than 120 days after order will be forfeited.
  • I understand and agree to Eyeworks Policy:

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  • AUTHORIZATION TO RELEASE MEDICAL RECORDS

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  • And I authorize Eyeworks of Decatur/Atlanta to receive medical records for the patient listed above to the following:

    Eyeworks of Decatur 404-377-3936 fax Eyeworks of Atlanta 678-732-3434 fax
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  • HIPAA PRIVACY

  • ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

    I have been provided with the Notice of Privacy Policy (the “Policy”) of this provider and have been offered a copy of such policy to keep for my records.
  • I hereby acknowledge that I have been provided or offered a copy of the policy.
  • I hereby refuse to receipt of the “Policy”. I understand even though I may refuse to sign this acknowledgment, my provider may still provide services.
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  • DILATION CONSENT

    Dilation of the pupil allows the doctor a view of the peripheral retina. The doctor can diagnose possible tumors, retinal holes or tears which could lead to retinal detachment. Please note that dilation will result in loss of near vision for approximately 90 minutes and light sensitivity for up to 7 hours. (There is an additional charge of $25 for dilation for all Groupon, Amazon and Living Social promotions)
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  • ALL SALES FINAL POLICY

    Eyeworks strives for prompt service. For that reason, your eye glass order is made with the labs and frame companies as soon as you place your order with Eyeworks. This is a completely personalized type of order and made just for the patient. Once you place your order and production has begun, there is no way to reverse or stop that order. For this reason all sales are final at time of purchase and there are no refunds. I understand and agree to Eyeworks All Sales Final Policy
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  • ADDITIONAL CONTACT LENS EXAMINATION AFTER ORIGINAL EYE EXAM POLICY

    Patient may receive a contact lens exam up to 60 days after original eye exam and only pay for contact lens exam. After that, a new eye exam must be performed by the doctor and charged to patient along with contact lens exam.
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