Welcome to Mascoutah Eye Care
VISUAL AND MEDICAL HISTORY:
Please check the following that apply to you and/or your immediate family members:
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CONTACT LENS INFORMATION:
YOU MUST READ AND SIGN THIS SECTION
Financial Assignment & Release
Mascoutah Eye Care
I, the undersigned, assign directly to Mascoutah Eye Care or Dr. Marianne McDaniel all insurance benefits, if any, otherwise payable by me or to me for services rendered.
*I understand that I am financially responsible today for all fees. I also agree that I am financially responsible to reimburse any
and all fees for services and materials not collected in full at the date of service or should my insurance or vision plan deny payment for services or materials rendered.
*I further understand that after 60 days from the date of service or claim is filed I agree to pay for any unpaid balances on my
account as a result of denial in part or whole from my insurance carrier caused by; unmet deductibles, non-covered materials or
professional services, my negligence in fulfilling any paperwork, providing any required information requested of me by my insurance carrier or uncollected fees on service day.
*If you do not inform us that you have a vision plan or medical insurance before services are rendered, we will assume no coverage exists.
* I agree that I am responsible to file my own claim if I discover I have vision or medical benefits after services or products are
*We will begin your custom glasses order immediately after receipt of payment. All glasses are custom crafted for each patient’s
unique vision needs. All glasses lenses are tailored to fit the frame with patient selected
*Cancellations on glasses will not be permitted. Patients may not switch frames after their order has been processed.
REFUNDS ARE NOT AN OPTION.
Starting April 14, 2003, Federal law requires us to inform you of privacy practices regarding patients’ records.
Copies of these privacy practices are posted in our waiting room. Please print and sign this form that state you
have been informed of this regulation. Thank you for your cooperation.
Mascoutah Eye Care is committed to offering our patients the most through eye health examination
available. We now offer optomap® ultra-wide field digital retinal imaging to obtain an in-depth view of
nearly the entire retina through an undilated pupil. As part of your comprehensive evaluation,
optomap® helps Dr. McDaniel better view and detect ocular disease and abnormalities, such as macular
degeneration, glaucoma, retinal holes, retinal detachments and diabetic retinopathy, in the retina at an
earlier and more treatable stage than methods previously available Your image will be obtained today
as part of our preliminary testing. Your doctor will review and discuss the optomap® images during the
In most cases
In most cases this technology may alleviate the need for dilation and allows the patient to return to
normal activities. Optomap® i is prescribed annually by Dr. McDaniel on each patient in order to identify
eye health problems and compare changes from year to year.
At Mascoutah Eye Care we consider optomap® retinal evaluation an important part of our patients’ eye
Optomap® is an advanced screening procedure that is traditionally not covered by most vision insurance
plans. Your fee for this elective diagnostic technology will be $39 unless covered by your insurance. The
doctor will let you know if this procedure is covered by your insurance when the image is reviewed.