Financial Responsibility & Acknowledgement of Privacy Practices
By signing below, I acknowledge that a copy of Claremore Eye Associates Notice of Privacy Practices has been made available to me. I hereby authorize any necessary medical treatment by the optometrists in the practice of Claremore Eye Associates, and agree to be financially responsible for my bill for materials and/or services rendered. I authorize this oce to release any information necessary to expedite insurance claims. I further authorize Claremore Eye Associates to release or obtain any required medical information from my attending physicians or any medical facility as necessary for my care and to decide which insurance plan should be billed for my services. I also authorize my insurance provider to make payments on my behalf to Claremore Eye Associates. Payments for services rendered are non-refundable. Your medical records will be electronically archived indefinitely, and all discarded documents are shredded to protect personal information. Our oce may use standard email to communicate with you for the purpose of sending payment receipts or copies of your glasses/contact prescriptions.
If you are signing for a minor, you attest that you have legal authority to make medical decisions for the minor. Please indicate any other parent, step-parent, guardian, or other individual(s) authorized to make medical decisions for the minor.
Please inform our Patient Services Coordinator if you have more than three medical insurance policies and need an additional sheet to supply the requested information.
Retinal Wellness Imaging Screening
Dr. Smith. Dr. Stover, and Dr. Crissup want ALL patients to have a digital image of the retina annually. The fee is only $35 (it is usually not covered by insurance). There is no charge for self-pay eye exams.
Retinal and optic nerve problems such as macular degeneration, glaucoma, diabetic retinopathy, and melanoma are easily documented, often without pupil dilation.
Early detection of eye disease is crucial!
***The flash during imaging is not recommended for patients with a history of epilectic seizures triggered by flashing lights. Please notify our staff if you have a history of such seizures.***