Riz Eye Care Sugar Land 
PATIENT HISTORY 
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PATIENT'S NAME 
DATE OF BIRTH *
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MOBILE NUMBER *
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E-mail  *
ADDRESS *
STREET ADDRESS, CITY, STATE, ZIPCODE
EMERGENCY CONTACT
NAME AND PHONE NUMBER 
HOW WILL YOU BE PAYING FOR YOUR VISIT? *
WHAT IS THE PURPOSE OF YOUR VISIT? *
OCULAR HISTORY (SELF) *
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MEDICAL (SELF) *
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DRUG ALLERGIES  *
LIST ALL DRUG ALLERGIES 
MEDICATIONS *
LIST ALL MEDICATIONS BEING TAKEN
MEDICAL (FAMILY) *
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Are you pregnant 
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Tobacco Use?
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Alcohol Use?
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RIZ EYE CARE DISCLOUSURE FEE(S)

FEES CHARGED IN THE OFFICE ARE FOR SERVICES RENDERED ONLY. THIS INCLUDES AND IS NOT LIMITED TO ANY DIAGNOSTIC TESTING, THERAPEUTICS, AND OCULAR/ FACIAL EXPERTISE.

 Medical History

 Additional testing may be required depending on one’s medical history. Some systemic diseases could affect your ocular health and impact your vision. Retinal Images, Visual Fields, and OCT scans are used to diagnose vision impairment and help us treat the underlying cause. If you decline additional testing, you understand we are not liable for issues with glasses and/or contacts. You also waive any future prescription verifications. 

These additional tests do have fees associated with them. 

- Retinal Image and interpretation $45.00

- OCT scans $95.00 each

- Visual Field $20.00

 Patients who have issues with their glasses and would like a prescription verification MUST bring eyewear in question to the visit within six months of service date or 6 months of purchase (receipt required) if the prescription is still valid. There will be a $35.00 charge for any prescription verification. If the issue is due to a doctor's change or any clerical error on our part the fee will be waived.

 Patients who are having issues with Contact Lens Trials MUST come to Follow Up wearing Contact Lens Trials so we can troubleshoot from there. If trials are not present you will be charged $45.00 for the contact lens follow up.

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By signing below you understand the following

- We do not sell products in our offices.

- Additional testing may be required due to your medical history (additional charges may apply).

- Prescription Verifications: Any issues with your eyewear not caused by the prescription will result in a $35.00 charge. If there is a prescription change, there will be no charge. 

-If you do not wear your contacts to your contact lens follow up there is a $45.00 charge (CL PATIENTS ONLY)

-All visits to the office are due and payable at the time of service

-All fees are for professional services and therefore are non-refundable

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DILATION *

Dilation is the opening of the pupils by using medicated eye drops. This allows a better view of the retina and helps the doctor to detect many eye conditions that may be missed during a routine eye exam. Dilation is strongly recommended for patients with a history of cataracts, high blood pressure, high prescriptions, and patients older than 40. However, dilation is mandatory for all diabetic patients, patients with a history of glaucoma, and children 12 and under.  After being dilated, you may experience blurred near vision and light sensitivity.  These side effects can last from 3-6 hours.

Signature (By typing your name below you agree to all of the terms mentioned above) *
VISUAL FIELD  *

Computerized device used to test your peripheral vision.  This test helps detect vision loss caused by glaucoma, retinal disease, stroke, injuries to the head, in addition to certain medications such as Chloroquine, Seizure medications, Antidepressants etc. that cannot be detected with a comprehensive dilated exam. With early detections, this test can prevent many blindness-causing diseases before it is too late.  This test does not require eye drops and takes 3-5 minutes to perform.  

The cost of this procedure is an additional $20 (If using insurance the cost of the VF will be $20)

Signature (By typing your name below you agree to all of the terms mentioned above) *
SIGNATURE ON FILE, ASSIGNMENT OF BENEFITS, FINANCIAL AGREEMENT, HIPAA NOTICE

1. HIPAA NOTICE OF PRIVACY PRACTICES:  I acknowledge that I have received availability of Notice of Privacy Practices issued by Riz Eye/ Northshore Eye/ Meyerland Family Eye Care that was effective April 1, 2005. Available at www.rizeye.com Hard copies available upon request.
2. RELEASE OF INFORMATION: Riz Eye/ Northshore Eye/ Meyerland Family Eye Care may disclose all or part of my medical record and/or financial ledger, including information regarding alcohol or drug abuse, psychiatric illness, communicable disease, or HIV, to any person or corporation (1) which is or may be liable or under contract to Northshore Eye Care for reimbursement for services rendered, and (2) any health care provider for continued patient care. A copy of this authorization may be used in place of the original. 
3. NON-COVERED SERVICES: I understand that Riz Eye/ Northshore Eye/ Meyerland Family Eye Care contracts with health care service plans (i.e., HMO’s, PPO’s) relate only to items and services which are “covered” by health care service plans. Accordingly, the undersigned accepts full financial responsibility for all items or services, which are determined by the health care, service plans not to be covered, including refraction fee (which is not covered by Medicare). I agree to cooperate with Riz Eye/ Northshore Eye/ Meyerland Family Eye Care to obtain necessary health care service plan authorizations. 
4. MEDICAL RECORDS REQUEST OR FORMS: Request for medical records must be made in writing by the patient. Records will be reviewed and released for a FEE of $25.00, it may take up to 30 days for records to be reviewed and released to patients. Any forms that need to be filled out by the provider will have a FEE of $25.00 to complete. This includes and is not limited to DPS FORMS, MMA FORMS, SCHOOL FORMS, CDL FORMS, etc. 
5. OTHER PROVIDERS: You may be scheduled with one of our highly qualified Optometric Assistants. All screening and tests are evaluated by our state licensed Optometrist who will assess your eye health and create your prescription. If you wish to speak with our state-licensed Optometrist, we offer telehealth visit before you leave the office. Additional Information can be located at www.rizeye.com
6. FINANCIAL AGREEMENT:  I agree that in return for the services provided to me by Riz Eye/ Northshore Eye/ Meyerland Family Eye Care, I will pay my account at the time service is rendered or will make financial arrangements satisfactory to Riz Eye/ Northshore Eye/ Meyerland Family Eye Care for payment. IF my account is sent to an agency for collection, I agree to pay collection expenses and reasonable attorney’s fees as established by the court and not by a jury in any court action. I understand and agree that if my account is delinquent, I may be charged interest at the legal rate. Any benefits of any type under any policy of insurance are hereby assigned to Riz Eye/ Northshore Eye/ Meyerland Family Eye Care. If my insurance company or health plan designates co-payments and/ or deductibles, I agree to pay them to Northshore Eye Care. However, I understand that I am primarily responsible for the payment of my bill. 
7. MEDICARE: I request that payment of authorized Medicare benefits be made on my behalf to Riz Eye/ Northshore Eye/ Meyerland Family Eye Care, for services furnished to me by Riz Eye/ Northshore Eye/ Meyerland Family Eye Care. I authorize any holder of medical information about me to release the centers for Medicare and Medicaid services and their agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorized release of medical information necessary to pay the claim. If other health insurance is indicated in Item 9 of the HCFS 1500 form or elsewhere on other approved claim forms, my signature authorized releasing the information to the insurer or agency shown. Riz Eye/ Northshore Eye/ Meyerland Family Eye Care accepts the charge determination of the Medicare carrier as the full charge, and I am responsible only for the deductible, coinsurance, and non-covered services.  Coinsurance and deductible are based upon the charge determination of the Medicare carrier.
8. MEDIGAP: I understand that if a Medigap policy or other health insurance is indicated in Item 9 of the HCFA 1500 form or elsewhere on other approved claim forms, my signature authorizes release of the information to the insurance or agency shown. I request that payment of authorized secondary insurance benefits be made on my behalf to Riz Eye/ Northshore Eye/ Meyerland Family Eye Care, if possible, or otherwise to me.
9.OTHER INSURANCE: I authorize payment of my medical and surgical insurance benefits to Riz Eye/ Northshore Eye/ Meyerland Family Eye Care. I understand that I am financially responsible for any charges whether paid by said insurance. If my insurance company or health plan designates co-payments and/or deductibles, I agree to pay them to Riz Eye/ Northshore Eye/ Meyerland Family Eye Care. 
10. MEDICAL PHOTOGRAPHY: may be taken at the time of your visit using a phone or iPad assigned to our office. The photographs taken are used strictly for diagnostic purposes and will be placed in your medical record. Refusal to consent to photographs will not affect the medical care you receive but could affect medical decisions making. If you have any questions, please contact our office. 
11. TEXT, EMAIL, CALL REMINDERS: You will receive messages related to appointment reminders. You can opt-out of receiving text messages at any time by replying "STOP" to any message from us. You may also contact us at [281-240-9555 or sugarland@rizeye.com] to unsubscribe. We are committed to protecting your privacy. We will not share your phone number with any third parties. For text messaging, message & Data Rates: Standard message and data rates may apply from your wireless carrier.

Signature (By typing your name below you agree to all of the terms mentioned above)
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THE DIFFERENCE IN VISION CARE FEES & MEDICAL CARE FEES

TO AVOID MISUNDERSTANDING AND CONFUSION ABOUT OUR PROFESSIONAL FEES FOR VISION CARE VS MEDICAL CARE, PLEASE READ AND SIGN THE FOLLOWING:

 

No Insurance Coverage

If you are healthy and have healthy eyes, wellness eye exam fees will be charged for your eye exam and/or contact lens exam to correct your nearsightedness, farsightedness, astigmatism, or presbyopia.

If you have a general health condition or an eye disease, then a medical eye exam fee will be charged for your medical eye care. (further explanation under Medical Insurance below)

 

Vision Plan and/or Medical Insurance

Many Patients have vision plans and many have medical insurance coverage for their eye care, some have both. Your eye care problem will determine which insurance carrier we will file with for your eye care visit. Often, there is no way to know before your examination which type of insurance we file. If you have questions about your insurance coverage and/or your eye care fees, please feel free to discuss them with our staff or providers.

 

A Vision Plan

A Vision Plan will pay for your wellness eye exam if you are healthy and have healthy eyes.

The results of your wellness eye exam are used to correct vision problems such as myopia, hyperopia, astigmatism, and/or presbyopia.

A Vision Plan usually (but not always) requires a co-pay if you are examined for contact lenses.

A Vision Plan does not pay for your examination if the examination requires medical decision making and/or the treatment of a medical eye condition.

 

Medical Insurance

Medical insurance will pay for your eye care if your examination requires testing and medical decision making because you have:

·         Systemic health problems (diabetes, high blood pressure, thyroid, etc.)

·         An eye disease (cataracts, glaucoma, diabetic retinopathy, allergic conjunctivitis, ocular surface disease, etc.)

·         A medical condition that requires taking high risk medication such as Plaquenil

 

If you have a medical problem or we discover a medical eye problem during the exam, we are required to furnish a medical level eye examination that is determined by your medical insurance carrier. The complexity of your medical condition and the level of decision making required to treat the problem are factors used to determine the exam fee level and co-payment amount. WE DO NOT SET THESE FEES, YOUR INSURANCE CARRIER DOES.

 

Also, depending on your medical problem, certain supplemental tests may be necessary. The fees for these tests are usually but not always covered by your insurance carrier. If covered, they often require you to pay additional co-pays. Medical Insurance Carriers have very specific guidelines regarding every aspect of your medical eye care testing and documentation which they require us as the provider by signed contract to follow. 

OUR OFFICE DOES NOT MAKE THESE RULES, THEY ARE MADE BY INSURANCE CARRIERS

IN THE EVENT WE DO NOT TAKE YOUR MEDICAL OR VISION PLAN, WE WILL PROVIDE YOU WITH AN ITEMIZED STATEMENT THAT YOU CAN FILE WITH YOUR CARRIER. I understand that once I opt to self-pay, I forfeit the right to submit these services for reimbursement to my insurance company. It is my responsibility to resolve any reimbursement directly with my insurance company, and Riz Eye Care/ Meyerland Family Eye Care/ Northshore Eye Care/ Tomball Eye Associates will not assist in this process.

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CONTACT LENS POLICY

Advancements in contact lens technology offer the potential of successful contact lens wear to most of our patients. Contact lenses are a medical device in contact with the tissues of your eye; therefore, they must fit appropriately to maintain the health of your eyes. A contact lens prescription can only be determined by the careful observation of the lens on the eye and the eye’s response to the lens on follow-up visits. Since follow up care is essential, it is your responsibility to keep all appointments and follow all lens care instructions.

THE COMPREHENSIVE EYE EXAM
Before a patient can be fit with contact lenses, a complete medical and refractive eye examination is necessary. This exam is critical to assure the good health of your eyes and to rule out the possibility of any unsuspected, underlying condition that may prevent contact lens use.

CONTACT LENS “FITTING” = Evaluation and Management
The goal of contact lens fitting is to find the most appropriate contact lens for each patient’s optimal vision and comfort. An enormous variety of types, materials, sizes and colors are offered. We are committed to taking the time and effort to fit your contact lenses properly. Although many patients will need only one fitting session, sometimes this process requires several appointments. In our experience, the extra time, effort and patience are well merited by both your ultimate satisfaction and the health of your eyes. All patients being fit into contacts for the first time must go through the fitting process. We will not finalize the contact lens prescription until both the patient and the doctor are satisfied with the fit and visual acuity of the contact lens. We will provide one set of trial lenses.

CONTACT LENS TRAINING SESSION $40.00 (FIRST TIME WEARERS ONLY)
The patient will be provided with personalized instruction concerning the safe care and usage of contact lenses. Upon completion of successful insertion and removal, the patient may begin wearing the contact lenses and we will schedule the first follow-up appointment. Online tutorials are also available for the convenience of the patient.

FOLLOW-UP APPOINTMENTS
Follow-up appointments are necessary to assure several things:
1. The contact lenses are fitting and moving well
2. The prescription is providing the best possible vision
3. The eyes are remaining healthy
4. There are no problems with insertion or removal
5. The patient understands and complies with the recommended wearing schedule.

There is no additional charge for the first two follow-up visits. Follow-up visits must be completed within 30 days of date of service.

ANNUAL CONTACT LENS CHECK
By law, a contact lens prescription is valid for only one year. All patients are required to come in for an annual contact lens exam. This is necessary to assure that the patient’s eyes are healthy, and the contact lenses are still fitting well. Contact lens prescriptions cannot be renewed without an annual exam. If we are seeing you for the first time, and you have had a contact lens prescription from another office, the doctor will use his/her judgment to use the prescription from another office for the fitting and prescription of the contacts, additional charges may apply.

CONTACT LENS SERVICE FEE POLICY
We do not sell contacts all fees are for services only. The fitting fee, which includes 2 follow-up visits within the first 30 days, is determined by the type of lenses prescribed, the difficulty of the fit, and whether the patient is a first-time contact lens wearer. THIS FEE IS NON-REFUNDABLE AND DUE AT THE TIME OF SERVICE. If an initial fitting needs to be changed, you will be charged the difference in the fitting fees between the original fitting cost and the final fit cost. Specialty fit lenses such as RGP and Sclerals have their own fee structure do to the complexity and expertise required. Once a decision has been reached by the patient and doctor, the parameters of the contact design, brand, powers, all fees will be charged regardless of if patient(s) decide afterwards for any reason they do not want to continue the process. Fees for service can only be determined after the doctor sees you. All the fees quoted by staff are estimates.

The fitting fee includes:
-The contact lens fitting
-Training sessions
-Follow-up visits within 30 days- fees will apply after 30 days
-Diagnostic lenses (if available)

The fitting fee does not include:
-Contact lenses (Costs will vary depending on type of lens prescribed)
-The comprehensive eye exam
-Medical visits not directly related to contact lens wear

Any pathology, infections not directly related to the contacts or due to negligence will need to be resolved prior to releasing the final prescription. This can only be determined by the doctor; office fees will apply

Annual contact lens exam: It is our policy that all patients that are currently wearing contact lenses be seen every year for a contact lens examination.


PAYMENT
Fees for the comprehensive exam, contact lens fitting, or annual contact lens checks are due at the time of service.


REFUNDS
There will be NO refund of the exam, fitting, or annual contact lens check fees.
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