Acknowledgement of Informed Consent
A. Review of Privacy Practices - HIPAA
In signing this form, you agree that you have received our Notice of Privacy Practices. This notices explains how we plan to use and disclose your protected health information for the purposes of treatment, payments, and health care operations. You have the right to review our Notice of Privacy Practices prior to signing this form. It provides more detail on how we may use and disclose your information. By signing this form, you acknowledge you have received our Notice of Privacy Practices and that Jackson Eye can use and disclose your protected health information in accordance with HIPAA.
B. Payment Policy
Your eye health services can be billed to your Vision/Medical insurance company. Jackson Eye is a provider for most of the major health insurance plans in the region. If we are not providers for your plan, we will be unable to file a claim on your behalf. However, we can provide you with a form that you can submit to your insurance company to instruct them to send reimbursements directly to you. Please be aware that with any health plans, there may be deductibles and co-payments for which you could be responsible. These payments are due at the time services are provided.
C. Retinal Evaluation $35
Dr. Jackson recommends every patient receive an Optomap. Retinal evaluation is considered to be a mandatory part of a routine eye exam. New technology allows eye doctors to evaluate the retinal nerves and blood vessels without dilating the pupils. At Jackson Eye, we prefer to use this new technology, referred to as an Optomap. The Optomap does not require that your eyes be dilated and allows Dr. Jackson to get better views of the entire inside of your eyes. This can help us to diagnose and treat eye conditions sooner.
D. iWellness Retinal Nerve Health Scan $25 (recommended for all DIABETICS and patients 50 AND OVER)
Vision insurance covers only the most basic examination of the eyes. The iWellness Retina Analyzer scans the thin layers of nerves in the back of the eyes and can detect early changes due to hypertension, diabetes, sarcoidosis, lupus, glaucoma, complications from cataract surgery, macular degeneration, multiple sclerosis, retinal diseases, some neurological diseases (such as brain tumors and optic nerve disease). Dr Jackson recommends this test for all diabetic patients, patients diagnosed with any of the above conditions and all patients 50 years of age and over.
By signing this form, I acknowledge that I understand all of the above.
Patient or Guardian (if under 18 years old)
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Patient Check In
Please have Medical and Vision cards available. Testing and/or treatment for certain eye conditions (pink eye, diabetes, glaucoma, etc.) is not considered as part of a "routine" eye exam and is therefore not covered by Vision insurance plans (VSP, EyeMed, Davis, etc.). We gather information about your medical insurance to cover the payment of these conditions if they are found during your exam.
Medications, Allergies, Social Factors