PLEASE BRING A LIST OF ALL MEDICATIONS TO YOUR INITIAL VISIT, INCLUDING EYE DROPS.
I request that payment of authorized insurance benefits be made either to me or on my behalf to Retina Consultants, San Diego, for any services provided. I authorize medical information about me to be released to insurance carriers to determine the benefits payable for services. I understand that my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If item 0 of HCFA-1500 claim form is completed, my signature authorizes release of the information to the agency shown. In medicine cases, Retina Consultants San Diego agrees to accept the charge determination of the Medicare carrier. The patient is responsible only for the annual deductible, coinsurance and non covered services.
I UNDERSTAND THAT DROPS MAY BE USED TO DILATE MY EYES AND MAY TEMPORARILY BLUR MY VISION. I WAS ADVISED TO AVOID DRIVING DURING THIS TIME OF POTENTIAL VISUAL IMPAIRMENT FOR MY OWN SAFETY AND THE SAFETY OF OTHERS.