Several procedures are required to examine the health of your eyes and determine treatment and/or the prescription for your eyewear. The comprehensive examination generally requires the instillation of eye drops to dilate the pupil of the eye. Dilating drops allow the doctor to examine the structures inside of the eye. These drops may result in light sensitivity, hazy vision, and difficulty focusing at near, for a duration of four (4) to eight (8) hours. Please exercise caution while driving, operating equipment, or reading during the duration of these effects.
I wish to ACCEPT DECLINE the DILATING EYE DROPS
DO YOU HAVE ANY VISION DISORDERS?
DO YOU HAVE HEALTH CONDITIONS?
DO ANY BLOOD RELATIVES HAVE VISION DISORDERS?
DO ANY BLOOD RELATIVES HAVE HEALTH CONDITIONS?
NOTICE OF PRIVACY PRACTICES
Our Notice of Privacy Practices describes in detail how your health information may be used and disclosed, and how you can access your information. By signing below, you acknowledge that you have been offered the opportunity to receive the Notice of Privacy Practices of the Vision Health Institute. Our privacy practices are posted online at www.myVHI.com.
FOR HEALTH INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
During the course of providing service to you, we create, receive, and store health information that identifies you. As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to safeguard your confidentiality. It is often necessary to use and disclose your health information in order to treat you, to obtain payment for our services, and to conduct health care operations involving our office. When it is appropriate and necessary, we provide the minimum necessary information to only those in need of your health care information.
When you sign this consent document, you acknowledge and authorize that we may disclose your health information for treatment, payment for our services, and to perform health care operations, which includes:
You have the right to restrict or revoke this consent in writing at any time unless we have already treated you, sought payment for our services, or performed health care operations in reliance upon our ability to use or disclose your health information in accordance with this consent. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI).
By signing below, you acknowledge that you have read and understand the above information and voluntarily consent to the statements herein.
As a courtesy to our patients, we participate in many health care insurance programs. Insurance is considered a method of subsiding professional fees for the patient and is generally paid directly to the doctor. Health insurance eligibility does not guarantee payment for services or materials and is not a substitute for your responsibility to pay for services provided.
Thank you for your confidence in our professional services and practice.We look forward to serving you.
This form is retained in your electronic medical record.