Kartesz Eye Care Valley View

Patient Name
First Middle Last
Date
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
DOB
Date Format: MM slash DD slash YYYY
Sex:
- M
- F
Social Security # or last 4 digits:
Marital Status:
Employer
Work Phone
Home Phone
Cell Phone
Email Address
Emergency Contact:
Medical Plan:
ID #:
Policy Holder Name:
First Last
Member Name:
First Last
Policy Holder SS No.
Policy Holder DOB
Date Format: MM slash DD slash YYYY
Member DOB
Date Format: MM slash DD slash YYYY
Vision Plan:
ID #:
Policy Holder Name:
First Last
Policy Holder SS No.
DOB
Date Format: MM slash DD slash YYYY
LIST MEDICATION:
Have you been seen at any of our other locations, if so check one:
- Electric Road
- Rocky Mount
- Peter's Creek Road
Financial Policy:
Initial and Sign below
Payment is due on the day of service.
All co-pays, non-covered services and materials and co-insurance amounts are due on the day of service. You must present a current insurance card and identification at the time of service.

Referrals are to be obtained by the patient from their primary care provider and must be presented before services are provided.
I will be responsible for charges to my family or me. If my account is sent to collections, all costs associated with collection or legal actions, including a 33 1/3% attorney fee will be due from me.
Materials not picked up within 90 days of notification will be returned to stock or donated. All monies paid will be forfeited.
Signature
I authorize the release of any medical or other information necessary to process a claim for services. I also request payment of government benefits either to myself or to the party to accepts assignment.

I authorize payment of medical benefits to the undersigned physician or supplier for services provided today.
Patient Signature
Date
Date Format: MM slash DD slash YYYY
HIPAA Acknowledgement Receipt:
The offices of Dr. Andrew Kartesz, O.D. and Associates have provided me with a copy of their HIPAA Policy.
Patient Signature
Date
Date Format: MM slash DD slash YYYY
Screening Wellness Testing:
While eye exams generally include a look at the front of the eye to evaluate health and prescription changes, a thorough screening of the retina and visual field is critical to evaluate the optic nerve and retina. This can lead to early detection of common diseases, such as glaucoma, diabetes, macular degeneration, and even cancer. The exam is quick, painless, and may not require dilation drops. These tests are in addition to the routine examination and are discounted to insurance allowable fee of $39.00. Each test separately is $20.00 each. If you choose to have these important screening tests, this amount will be due from you today.
Yes, I would like the doctor to provide these tests today.
Patient Signature

Financial Policy:

HIPAA Acknowledgement Receipt:

Screening Wellness Testing: