Welcome to our office--
It is our true pleasure to have you here today. We strive to offer patient-centered eye and vision care. Please complete the following to help us get to know you and tailor your exam to your exact needs.
Insurance Information (if applicable)
Review of Systems
Please note any family history (parents, siblings, children; living or deceased) for the following conditions:
Optomap Retinal Screening Photography
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 is critical to verify that your eye is healthy. This can lead to early detection of common diseases, such as glaucoma, diabetes, macular degeneration, and even cancer. The photos are quick, painless, and may not require dilation drops. More than 80% of your retina can be evaluated in one single image while traditional imaging methods typically only show 15% of your retina at one time. These photos will become a part of your medical records and will allow the doctor to compare them with subsequent photos at future exams in order to detect even the smallest amounts of change. Dilation is the only way 100% of your retina can be seen and can also help reduce the affects of your/your child's focusing which allows for a more accurate prescription.
Assignment of Insurance Benefits, Recall Program & Office Business Policies
I, the undersigned may have insurance coverage and/or vision plan coverage with an insurance carrier(s)/ or surgical benefits, if any, otherwise payable to me for services rendered. I hereby request that Bhend Family Eye Care, PLLC dba You and Eye to file any claim(s) for medical and or/ preventative care benefits with my medical carrier prior to filing a claim(s) with any vision plan carrier or free standing vision plan unless I indicate otherwise at time of service. I hereby authorize the release of all information necessary to secure the payment of benefits.
As part of Dr. Bhend's annual recall program, I authorize Bhend Family Eye Care, PLLC dba You and Eye to utilize my name, mailing address, phone number, e-mail address and next appointment date and time to Bhend Family Eye Care, PLLC dba You and Eye for the purpose of providing annual reminder postcards, coupons and product information.
I understand that I am financially responsible for all charges whether or not paid by insurance or vision plans; Co-pay, Co-insurance, and Deductibles are due at the time of service; Contact lens fitting fees, which are not generally covered by insurance nor a part of a routine eye exam, are due at the time of service; Bhend Family Eye Care, PLLC dba You and Eye charges $30.00 for any check returned from your bank; returned check fee(s) will be added to my unpaid balance and must be paid by credit card or in cash. Contact lens fitting fees are good for 90 days from date of original contact lens fitting; any contact lens fitting not completed within 90 days may incur additional fees.
I acknowledge that I have either been given access to and reviews or received a copy of the Office's Notice of Privacy Practices, ("Notice") which describes how my health information is used and shared. I understand that the Office has the right to change this Notice at any time. I may obtain a current copy by contacting the Office Privacy Officer.
- CLICK HERE TO VIEW OUR NOTICE OF PRIVACY PRACTICES
If you do not wish to receive text messages or email notifications please VERBALLY notify a staff member so we may modify your file.
Notice of Privacy Practices
In signing this authorization to release my protected health information, I acknowledge that I understand my right to medical information confidentiality and authorize You and Eye Family Eye Care Center to discuss all my medical health information with the individual)s) listed below: