Welcome to Cary Vision Care patient intake forms.
This process consists of three sections. Please review each section and sign where indicated. You will see a confirmation screen when you've completed all three sections.
Thank you for choosing Cary Vision Care.
Your information
Enter this once — it applies to all three sections.
Patient Responsibility Policy
Cary Vision Care, O.D., P.A. — 1100 NW Maynard Rd. — Cary, NC 27513 · 919-467-9834 · Fax 919-466-0045 · contact@caryvisioncare.com
The patient (or patient's guardian if a minor) is ultimately responsible for the payment of provided care, treatment, and/or materials.
Payment is due at time of service and/or when materials are ordered. We do not offer payment plans, or accept Care Credit plans. We do accept all credit cards, including HSA cards, and personal checks, but proper ID is required, and a $30 fee will be charged for all returned checks.
Outstanding balances must be paid before additional services are provided, or additional materials are ordered.
If you have insurance, you are required to provide all insurance information before your appointment so that we can verify benefits are available. We will bill your medical or vision insurance if we participate with your plan. Insurance copays are due at time of service, and overages for materials are due at time of order. Payment for coinsurance, deductibles, and non-covered services will be your responsibility, and will be due within 30 days of billing.
You will be private pay if:
- You do not have insurance
- We do not participate with your insurance plan
- You have not provided accurate insurance information and we cannot confirm eligibility
- Your plan requires a referral, and it is not on file by your appointment time
You must give us notice, no later than 24 hours prior to your appointment time, if you need to cancel or reschedule. If you do not notify us in the required time, or fail to show, you will be charged a $50 fee. If you are 15 minutes late for your scheduled appointment, you will be required to reschedule and charged a no show fee.
Custom Eyewear Policy
All prescription eyeglasses, prescription sunglasses, custom lenses, and specially ordered frames are custom-made specifically for you and are non-refundable and non-returnable once your order has been placed with the laboratory.
If your eyewear has a manufacturing defect or was made incorrectly due to an error by Cary Vision Care or the laboratory, we will repair or remake it at no additional charge.
By placing your order, you acknowledge and agree to this Custom Eyewear Policy.
By signing below, I acknowledge that I have read, understand, and agree to the above office policies.
Your signature is required to submit.
Medicare patients only
Most Medicare plans do not consider the refraction as a covered benefit. The refraction fee for Medicare is $45.00, and must be paid by the patient at the time of service.
Medicare patients only need to check this box. All other patients can continue.
Receipt of Notice of Privacy Policies & Consent Form
Cary Vision Care, O.D., P.A. · 1100 NW Maynard Rd, Suite 120 · Phone (919) 467-9834 · Fax (919) 466-0045 · contact@caryvisioncare.com
In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services and to conduct healthcare operations involving our office.
The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. You are free to refer to this notice at any time before you sign this form. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and service provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes (1) our submission of your health information to a billing agent or vendor for processing claims or obtaining payment; (2) our submission of claims to third-party payers or insurers for claims review, determination of benefits and payment; (3) our submission of your health information to auditors hired by third-party payers and insurers; and (4) other aspects of payment described in our Notice of Privacy Practices. Our Notice of Privacy Practices will be updated whenever our privacy practices change. You can get an updated copy here at the office (or from our website).
When you sign this consent document, you signify that you agree that we can and will use and disclose your health information to treat you, to obtain payment for our services and to perform healthcare operations. You also signify that you have received a copy, if requested, of our Notice of Privacy Practices.
You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment or healthcare operations, but as described in our Notice of Privacy Practices, we are not obliged to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.
I, the patient, hereby authorize Cary Vision Care to release my medical information (appointments, lab/test results, diagnoses, medications, surgeries, prescriptions for eyewear, etc.) to the following individuals:
Optional. Add as many people as you'd like.
I have read this document and understand it. I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations. I acknowledge that if requested, I would receive a copy of the Notice of Privacy Practices from Cary Vision Care.
Your signature is required to submit.
Eidon Ultra-widefield Retinal Imaging
Cary Vision Care is committed to utilizing the very latest technology to assess the health of your eyes.
Dr. Stikeleather and Dr. Dantini recommend that all patients have a yearly retinal screening with Eidon Ultra-widefield retinal imaging. This allows for earlier detection of eye disease and provides a permanent record that can be used to identify subtle changes in eye health from year to year.
Eidon Ultra-widefield retinal imaging gives our doctors a high definition, 200-degree view of your peripheral retina. This scan can help detect:
- Retinal detachment, tears, or myopic (nearsighted) degeneration/thinning
- Diabetic retinopathy
- Drug toxicity
- Ocular melanoma
Eidon Ultra-widefield photos do not replace routine dilation of your pupils. However, we will not have to dilate your eyes as frequently if you have annual Eidon photos.
While some insurance plans cover annual screening with Eidon, many do not. We believe in the value of this technology and want it to be accessible to all of our patients.
If not covered by your vision plan, our fee for Eidon Ultra-widefield screening is $39.
Please note: If you have a medical condition that requires retinal imaging to document and monitor your condition, we will bill your medical insurance, and you will be responsible for any copay, coinsurance, and/or deductible charges according to your plan.
Your signature is required to submit.