*We must have a copy of all insurance cards on the day of service*
NOTICE OF PRIVACY PRACTICES: I/We have been offered a copy of Total Vision Family Eye Care statement on privacy practices.
AUTHORIZATION TO RELEASE INFORMATION: I/We hereby authorize Total Vision Family Eye Care to release any medical or incidental information that may be necessary for medical benefit of in processing applications
for financial benefit. This includes but is not limited to my insurance company, Rehabilitation Services, Social Security Administration, and Worker’s Compensation.
CONSENT FOR TREATMENT: I/We hereby authorize Total Vision Family Eye Care to administer diagnostic and medical procedures as may be necessary for proper health care.
OFFICE POLICY ON PAYMENT: I understand that I am responsible for payment of all charges. As a courtesy, my insurance will be billed for me. It is my responsibility to pay any deductible, copay or any other balance not
paid by my insurance company. I authorize insurance benefits to be paid directly to the provider.
VISION PLAN COVERAGE: I/We understand that only one vision plan may be used for exam/materials per visit-per patient and that the vision plan to be used must be chosen before the exam occurs and can not change at a
later date. If I do not supply my vision plan at the time of services I will be required to pay up front and self-submit on my own.
How can we help you today? In this space please check/explain any signs and/or symptoms you are experiencing. Medical insurance will only cover if there is a medical reason for the exam/test such as loss of vision, headaches, eye pain, eye itching or burning, redness, glaucoma, cataracts, floaters, dry eyes, etc.
History of Present Illness
If yes, answer the question below; if no, continue to contact lenses section.
If yes, answer the questions below; if no, continue to past ocular history section
Review of Systems