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Download La Vernia Family Eye Care MEDICAL EXAM VS ROUTINE EXAM
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La Vernia Family Eye Care MEDICAL EXAM VS ROUTINE EXAM PLEASE READ CAREFULLY AND SIGN AT THE BOTTOM OF THE PAGE IF YOU CHECK ANY CONDITION BELOW YOU WILL NEED TO PROVIDE US WITH YOUR MEDICAL INSURANCE CARD AND YOUR EXAM WILL BE FILED UNDER YOUR MEDICAL INSURANCE. ANY MEDICAL CO PAYS OR DEDUCTIBLES WILL APPLY. A medical exam starts anywhere from $165 and up for those without insurance or who have not met their deductible. MOST CONDITIONS ON THIS PAGE ARE CONSIDERED MEDICAL AND WILL NOT BE COVERED BY YOUR VISION INSURANCE. (Vision Insurances include VCP, VSP, Davis Vision, Eyemed, Opticare, Optum Health/Spectera, Safe Guard,Superior Vision, Avesis, block vision, etc). Your vision insurance only covers a well routine exam for healthy patients. This is not our choice as providers. If we do not file your exam appropriately it is considered insurance fraud. Please also understand that we cannot file medical conditions (medical insurance) on the same day we update your glasses or contact lens prescription (using your vision insurance). These must be assessed on separate days if you would like us to file through your insurance. If any of the conditions below apply we need to assess those at the initial visit. THE SYMPTOMS & CONDITIONS BELOW MUST BE FILED UNDER YOUR MEDICAL INSURANCE (PLEASE CHECK IF ANY OF THE BELOW CURRENTLY APPLY TO YOU) ___ Ocular Allergies ___Dry Eyes/Sandy Feeling ___Ocular Burning ___Irritated Eyes ___Watery Eyes ___Red Eyes ___Ocular Bumps ___Eyelid Problems ___Eye Pain/Soreness ___Infection of Eye/Lids ___Trauma/Burn ___Eye Turn ___Scratched Eye ___ Flashing Lights ___Floating Spots ___ Blindness ___Glaucoma ___Cataracts ___Macular Degeneration ___Temporary Loss of Vision ___ Permanent Loss of Vision ___ Permanent Shadow/Curtain Over Vision ___History of Retinal Holes, Tears, Detachment, Lattice Degeneration or any other Retinal Conditions ___Itchy Eyes ___Mucous/discharge ___Foreign Body Sensation ___Blackouts ___Matted Eyes ___Diabetes (Type I) ___Diabetes (Type II) (If you have diabetes your exam is medical unless you provide us with a recent report from your ophthalmologist) THE SYMPTOMS BELOW MAY LEAD TO AN OCULAR MEDICAL CONDITION (PLEASE CHECK IF ANY OF THE BELOW CURRENTLY APPLY TO YOU) ___ Seasonal Allergies ___Double Vision ___Glare ___Migraines ___Night Blindness ___Twitching Eye ___Light Sensitivity ___Headaches ___Halos ___feeling of pressure ___Lazy/Turned/Amblyopic Eye ___ AIDS/HIV ___Cancer ___Hepatitis ___High Blood Pressure ___Herpes Simplex/Cold Sores ___Vascular Disease ___Stroke/CVA ___ Arthritis ___Skin Conditions ___Herpes Zoster/Shingles ___Multiple Seizures ___Epilepsy ___Lupus ___Thyroid Dysfunction ___Hormonal Dysfunction ___Crohn’s Disease ___High Cholesterol ___Sinusitis ___Rheumatoid Arthritis ___Sjogren’s Syndrome ___Anxiety ___Tumor ___Rosacea ___Psoriasis or Eczema ___Any Sexually Transmitted Diseases ___Any Other Medical Conditions________________________________________________________________________________ ___List Any Systemic/Medical Surgeries____________________________________________________________________________ ___NO CONDITIONS ABOVE APPLY BY SIGNING BELOW I INDICATE I HAVE FILLED OUT THIS FORM TRUTHFULLY AND TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT MOST OF THE CONDITIONS ABOVE WILL NOT BE COVERED BY MY VISION INSURANCE AND ACCEPT THAT MY EXAM WILL BE FILED UNDER MY MEDICAL INSURANCE. PRINT PATIENT NAME:__________________________________________ PATIENT DATE OF BIRTH _____/_____/________ PRINT GUARDIAN NAME AND RELATION IF APPLICABLE:________________________________________________________ SIGNATURE:_______________________________________________________________ DATE:____________________ (PATIENT OR IF PATIENT UNDER 18 GUARDIAN MUST SIGN)
