Demographics & Insurance Information
Do you have vision insurance?
Do you have health insurance?
Do you have medicare?
Primary Care Physician Address
I request that payment of authorized Medicare or other assigned insurance be made directly to Hopkinton Eye
Associates for any services rendered. I authorize this holder of medical information about me to release to CMS and
agents and information to determine these benefits payable for related services.
I understand that I am responsible for any non-covered services
Notice of Privacy Practices
I acknowledge that I have been offered a copy of the Notice of Privacy Practices.
Most insurance carriers will not cover procedures related to contact lenses unless they are “medically necessary”.
Most contact lenses are for cosmetic purposes. Please ask us for a quote of these additional fees.
Screening Retinal Photos
To ensure the thoroughness of your eye exam, the doctors at Hopkinton Eye Associates
recommend having digital retinal photos taken on all our patients.
The procedure consists of simply taking a digital photograph of the back part of each of your
eyes (retina). This is not an X-Ray or ultrasound procedure, and the camera does not touch
you. You will be able to view and go over these photos with your doctor immediately after
they are taken
What parts of the eye can be seen in the photos?
The Optic Nerve, Macula, Arteries and Veins, Retina, Choroid
What diseases can be detected or monitored with dilation and photos?
Glaucoma, Macular Degeneration, Signs of Diabetes, Ocular Melanoma, Hypertension and
Heart Disease, Drug induced Ocular manifestations, and many more...there are just too many
Reason for this extra test:
These photos become permanent invaluable data in your record, and allow the doctors to
evaluate any changes over time by comparing your baseline photos with future visits.
This screening is NOT covered by insurance, and requires an additional fee of $39 at the time
of your visit.
You will have an opportunity to discuss this with your doctor during your exam. Please sign
below to show that you have read and understood this explanation sheet.
I would like to have retinal photos taken at this time.
List medications you take (including oral contraceptives, aspirin, over-the-counter medications, and home remedies)
List all allergies to medications
Indicate any of the following that you have had:
age-related macular degeneration
Do you wear glasses?
Do you wear contact lenses?
Type of contact lenses:
Are they comfortable?
Please note any family history (parents, grandparents, siblings, children: living or deceased) for the following conditions:
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
I prefer to discuss my Social History information directly with the doctor.
If yes, do you have visual difficulty when driving?
Do you use tobacco products?
Are you a
Do you drink alcohol?
Do you use illegal drugs?
Review of Systems
Do you currently, or have you ever had, any problems in the following areas:
High Blood Pressure
Congestive Heart Failure
Herpes Simplex/Cold Sores
Large Volume Blood Loss
If you answered yes to any of the above, or have a condition not listed, please explain:
Medfield/Hopkinton Eye Associates acknowledges that it is a privilege to provide eye care to
your family. We would like to give the best care at a reasonable fee. In order to hold billing
costs to a minimum we expect payment at the time services are rendered, unless prior
arrangements have been made. In order to be able to continue to see our patients in a timely
manner for urgent issues we will charge a $40 fee for appointments which are not cancelled 24
hours in advance.
As per your contract with your insurance company, at the time of service you are to:
Present your insurance card and inform us of any vision plan.
Be prepared to pay your co-payment/co-insurance as stipulated in your contract (found on the face of your insurance card). In most cases, no co-pay will be collected for preventative services. However, if additional issues are addressed during the visit, a copay will be required.
Inform the office of any insurance, billing or contact (telephone/address) changes.
Be prepared to pay any deductible as stipulated in your contract with your insurance company. It is your responsibility to check the status of your deductible with the insurance company. We are unable to do this for you since we are not privy to this information so please review this information prior to your visit.
For your convenience we accept MasterCard, Visa, Discover, Amex, checks or cash. If your
check is returned for non-sufficient funds, the bank will debit your account for the amount of
the check, plus any applicable fees and we will bill you a $25 service charge. The use of a check
for payment is your acknowledgement of this policy.
If someone other than a parent brings your child for care, they must provide the above
information and pay the appropriate charges on your behalf.
Our Eye Doctors have earned the
trust and respect of our patients
for being dedicated to your vision and your eye health.
CONTACT US TODAY
Medfield Eye Associates (508) 359-4164
Hopkinton Eye Associates (508) 497-9500