Agreements & Forms
Clients are required to complete a consulting agreement prior to work being performed. A monthly maintenance agreement is also required to participate in our Monthly Maintenance Program. In addition, the Health Insurance Portability and Accountability Act (HIPAA) requires Medicare providers to obtain a Business Associate Agreement from entities they engage that may have access to confidential patient information. HIPAA requires this agreement to protect patient privacy.
As a courtesy to current and prospective clients, these agreements may be downloaded below.
Some forms required by Medicare must contain specific language. Without the proper Medicare wording, a form could be considered invalid and not taken into consideration in the event of a Medicare audit. Please take a few minutes to review the forms below and compare them to the forms currently in place in your practice. As a courtesy to current and prospective clients, any of the forms may be downloaded for your use.
- Advance Beneficiary Notice
- Deluxe Frames Waiver
- DME Supplier Standards
- Extended Ophthalmoscopy Sheet
- Financial Hardship Waiver
- Interpretation & Report- Generic
- Interpretation & Report- Pachymetry
- Lifestyle Impairment Questionnaire
- NEMB - Astigmatism-Correcting IOLs
- NEMB - Presbyopia-Correcting IOLs
- Obtaining Chief Complaints
- Patient Authorization
- Prescription for Glasses
- Transfer Of Care Form
Need Adobe Acrobat Reader?
If you do not have a copy of Acrobat Reader you can get one for free by clicking on the icon 'Get Acrobat® Reader'. This will take you to Adobe's website and enable you to download the Acrobat program to your computer.
