Client Intake Form
HIPAA COMPLIANCE
Notice of Privacy Practice
I ACKNOWLEDGE THAT I HAVE RECEIVED AND REVIEWED THE NOTICE OF PRIVACY PRACTICES FOR THE OPTICAL EXPERIENCE. IF YOU WOULD LIKE A COPY EMAILED TO YOU FOR YOUR RECORDS PLEASE LET US KNOW.
INSURANCE ASSIGNMENT AND PAYMENT AUTHORIZATION
I AUTHORIZE ABITA EYE GROUP/THE OPTICAL EXPERIENCE TO FILE CLAIMS WITH MY INSURANCE PROVIDER ON MY BEHALF FOR EYE CARE SERVICES RENDERED AT THE OPTICAL EXPERIENCE. I ALSO AUTHORIZE PAYMENT OF BENEFITS DIRECTLY TO ABITA EYE GROUP/THE OPTICAL EXPERIENCE FOR SERVICES PROVIDED.
THANK YOU
WE ARE DELIGHTED TO HAVE YOU AS A VALUED CLIENT. OUR GOAL IS TO PROVIDE YOU WITH A CURATED VISION EXPERIENCE THAT PERFECTLY FITS YOUR LIFESTYLE AND NEEDS. IMPORTANT INFORMATION AND DISCLAIMER PRESCRIPTION RIGHTS: YOU ARE ENTITLED TO A COPY OF YOUR PRESCRIPTION ONCE THE EXAM HAS BEEN COMPLETED AND PAID FOR IN FULL. PAYMENT POLICY: PAYMENT FOR YOUR EXAM IS DUE AT THE TIME OF YOUR APPOINTMENT. GLASSES CAN BE PAID FOR EITHER IN FULL AT THE TIME OF ORDER OR THROUGH OUR AVAILABLE PAYMENT PLAN OPTIONS. ALL SALES FINAL: PLEASE NOTE THAT ALL EYEWEAR SALES ARE FINAL. HOWEVER, ALL GLASSES COME WITH ONE FREE REMAKE DUE TO PRESCRIPTION CHANGES. WE DO NOT OFFER RESTYLES DUE TO OUR EXTENSIVE FITTING PROCESSES. WE DO HONOR NON-ADAPTS WITHIN 90 DAYS, AND ALL PRESCRIPTION CHANGES MUST BE MADE WITHIN 90 DAYS OF THE ORIGINAL EXAM. EXAM DURATION: THE EXAM PROCESS TYPICALLY TAKES 1.5 HOURS. IF YOU ARE UNABLE TO STAY FOR THE ENTIRE DURATION, WE ARE HAPPY TO RESCHEDULE YOUR APPOINTMENT TO A MORE CONVENIENT TIME. FOLLOW-UP POLICY: ANY FOLLOW-UPS NOT COMPLETED WITHIN THE ALLOWED TIME FRAME WILL BE SUBJECT TO A CHARGE FOR A NEW EXAM. REQUESTING RECORDS: IF YOU NEED A COPY OF YOUR RECORDS. YOU CAN REQUEST THEM BY EMAILING US AT DESTYNEE@MYOPTICALEXP.COM OR BY CALLING US AT 561-401-0902.
