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Northwest Family Eyecare
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  • Patient Information

  • Social History

    NOTE: This information is kept strictly confidential. However, you may discuss it directly with the doctor if you prefer.
  • Medical History

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  • Eye History

  • Review of Systems

  • Dilation Of The Pupils

  • Dr. Rosa C. Suarez-­‐Reyna and Associates strongly recommend that all patients’ pupils be dilated as part of a comprehensive eye examination. Routine dilation of the eyes is recommended at least every 2 years. If you have a condition such as diabetes, high blood pressure, cataracts, headaches, high myopia (nearsightedness), symptoms of flashes of lights or floaters, glaucoma or a family history of glaucoma, you are strongly urged to have your pupils dilated yearly. Dilation involves placing drops in your eyes to enlarge the pupil size. When an eye is dilated, we are able to get a much broader and fuller view of the inside of the eye. This aids the doctor in determining if diseases (such as macular degeneration, glaucoma, and tumors) are present, if there is damage to the retina (such as holes or tears) and in the evaluation of cataracts.

    With pupillary dilation, you may experience the following effects:

    • Increased sensitivity to light
    • A slight blurring of your distance vision
    • Inability to focus up close

    Every patient is different and therefore these effects my last 2-6 hours

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  • Payment Policy

  • This information is provided so that our clients are fully informed of our policies. Please read and sign below

    Fees: Our fees reflect the level of care that you receive and the training of the doctors. Estimated amounts of services may be given, but the final amount may be different depending upon the employer plan and other circumstances

    Insurance: Your policy is a contract between you and your insurance company. As a courtesy, we bill your insurance carrier, but you are ultimately responsible for the entire bill. If your insurance company does not pay the practice within 90 days, we will expect payment from you. If we later receive a check from your insurer, we will refund your overpayments. Unpaid balances accrue interest at the rate of 1.5% monthly (18% APR) and are send to a Collection Agency after 120 days. If you insurance plan determines a service is not covered, you will be responsible for the full charge. Co-pays, deductibles, and co-insurance are required on the day of service. If the co-pay is not paid at the time of service, a $10 billing fee will be charged. Uncollected fees, either from the insurance, insufficient funds check, stop payment, credit card chargebacks, etc. remain the responsibility of the patient (parent or legal guardian, if a minor). When insurance benefits are verified, the information provided by the customer service representative is NOT A GUARANTEE OF PAYMENT

    Materials: Contact lenses require half-down prior to ordering. Glasses require full payment prior to dispensing

    Assignment of Benefits: (Applicable if we are filing with Vision or Medical Insurance for you.) At each visit, patients are questioned about any changes in their insurance coverage and insurance card is copied. This is crucial so that your visit is billed correctly. We require all patients to sign a copy of the patient registration form that assigns insurance benefits to be directly to Northwest Family Eye Care, PLLC. If your insurance company sends a payment directly to you, it is your responsibility to make payment to Northwest Family Eye Care, PLLC.

    "I hereby authorize my insurance/medical benefits to be paid directly to Northwest Family Eye Care, PLLC. I further authorize release of any medical records or information necessary to process this claim." This assignment of benefits may be revoked by the patient at any time, with prior written notice.

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  • Acknowledgement of Notice of Privacy Practices

  • I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.

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  • Disclosure of Medical Information Consent

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  • Emergency Contact Information

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