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407-333-7333
407-333-7313
Schedule an Appointment
  • About Us
    • Contact Us
    • Blog
    • Events
    • Reviews
  • Services
    • Telemedicine
  • Shop Online
    • Browse Eyewear
    • REFRESH®
    • Virtual Try-On
  • Patient Center
    • Patient Forms
    • Patient Satisfaction Survey
  • Appointment Request
Logan Eye Care

Patient Information

MM slash DD slash YYYY
Date of Birth(Required)
Address(Required)
Please Select One(Required)
Student?
Physician Address
Pharmacy Address

Insurance

Policy Holder DOB
Guarantor/Name of person responsible for this account:
Relationship of Guarantor to Patient

I certify that I have read and understand the information on this form, and have answered the questions accurately and to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health. I understand and agree to be financially responsible of all services rendered on my behalf or my dependents.

MM slash DD slash YYYY
Date of Last Eye Exam
Do you wear glasses?(Required)
Do you wear contact lenses?(Required)
Are you interested in contacts?(Required)
Are you interested in Laser Vision Correction?(Required)

Medical History

Do you or have had any of the following medical conditions? If yes, please explain, include date of diagnosis and medications you are CURRENTLY taking:
Eye Injuries
Eye Surgery
Loss of vision
Glaucoma
Macular Degeneration
Cataracts
Retinal Detachment
Diabetic Eye Disease
Amblyopia/Strabismus
Dry Eyes
Legal Blindness
Any other eye disease
Seasonal allergies
Rheumatoid Arthritis, Lupus, other autoimmune disease
Heart disease
High Blood Pressure
Diabetes
Thyroid Condition:
Cancer
Asthma
Cholesterol
List medications
List surgeries

Social History

Do you have difficulty driving during the day?
Do you have difficulty driving at night?
Do you drink alcohol?
Do you smoke?
Have you ever had a blood transfusion?
Date
Work on a computer?
Have prescription sun glasses?
Participate in recreational sports?
Do you do a lot of reading?
Want information on Laser Vision Correction?

Demographics

With recent changes in healthcare laws, as well as our efforts to provide the highest quality of care to our patients, Logan Eye Care has upgraded our computer system to a certified Electronic Health Care Records system.

The new system will allow us to offer more comprehensive care to our patients and will also give patients easy access to their medical records. In order for us to accomplish that goal and meet the HER required guidelines, we ask that you provide us with additional information for your medical records:

Preferred Language
Race (check one or more that apply)
Ethnicity
Preferred methods of communication
Do you smoke or have you smoked in the past?
Previous Smoker?
Please list any prescription drug allergies
MM slash DD slash YYYY

Financial and Insurance Policy

Thank you for choosing Logan Eye Care as your vision care provider. As a part of our services, we request you read and sign the following financial policy prior to services being rendered. Patient or responsible party must complete our information and insurance form before seeing Dr. Carol Logan.

  • Full payment, co-payment, percentages and/or deductibles are due at the time services are rendered.
    We accept cash, checks, Visa, MasterCard, American Express and Discover. If you are purchasing eyewear or contacts, payment is due prior to any order being processed.
  • Office Policy: Insurance is billed as a courtesy to our patients; however, the patient is the final responsible party. If your insurance has not paid within 60 days you will be notified. Returns or cancellations are made at the discretion of the office administrator and office credit will be issued in lieu of refunds. Please make your selection carefully.
  • Minor Patients (under the age of 18): The adult accompanying a minor (patient/guardian) is responsible for full payment at the time of service. For unaccompanied minors, payment arrangements need to be made in ADVANCE and we must have parents or guardians written permission prior to treatment of a minor.
  • Returned Checks: A $25.00 service charge will be applied to your account for returned checks. No returned checks will be re-deposited. All balances must be paid in cash or by credit card. One attempt will be made to collect this debt from the patient, if not collected within 5 days of the returned check; the account will be turned over to collection agency. We request a copy of your driver’s license for our records if you wish to make payments by check.
  • Spectacle Prescription: Patients have 30 days follow-up care from the date of the fitting to make any changes in the prescription necessary. However, the Optician will be happy to check the prescription of your glasses against your prescription given by Dr. Logan at any time.
  • Eye wear and contact lens prescriptions that are filled elsewhere are not warranted by Logan Eye Care.
  • Contact Lens Patients: Additional time and testing is required for the fitting and evaluation for contact lenses. Additional professional fees will be applied, and are generally not covered by your insurance company. Patients have 30 days follow-up care from the date of the fitting to make any changes in the prescription necessary. A contact lens prescription is only valid one year from the exam date and cannot be filled once expired. Disposable contacts have been ordered and received by the patient, they cannot be returned.
  • Emergency Visits: There will be a $50.00 fee charged above and beyond the usual and customary fees if seen outside of office hours.
  • Eyeglass and contact lens prescriptions (when requested) are faxed by the end of each business day.

Please realize that:

  1. Your insurance is a contract between you, your employer and the insurance company. We are not a party in the contract.
  2. You are responsible for all charges that are denied/not covered by your insurance company. Not all services are covered under insurances – glasses, contact lenses and/or contact lens fitting or evaluations and some procedures performed by Dr. Logan.
  3. Although we verify your coverage through your insurance company with each and every patient, verification of benefits is not a guarantee of payment from your insurance company. We request that you present a copy of your insurance card for our records if necessary or any discount plans that are being utilized. Only one insurance / discount plan is accepted, per patient, per year.
MM slash DD slash YYYY

Patient Acknowledgement

Notice of Privacy Practices

Our Notice of Privacy Practices describes in detail how your health information may be used and disclosed, and how you can access your information.

By signing below, you acknowledge that you have received a copy of the Notice of Privacy Practices of Carol Logan, O.D., and Logan Eye Care.

MM slash DD slash YYYY

Consent of Disclosure

For Health Information For Treatment, Payment, and Health Care Operations

During the course of providing service to you, we create, receive, and store health information that identifies you. As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to safeguard your confidentiality. It is often necessary to use and disclose your health information in order to treat you, to obtain payment for our services, and to conduct health care operations involving our office. When it is appropriate and necessary, we provide the minimum necessary information to only those in need of your health care information.

When you sign this consent document, you acknowledge and authorize that we may disclose your health information for treatment, payment for our services, and to perform health care operations that includes:

  • The use and disclosure of your health information for treatment purposes, not only includes care and services provided here, but also disclosures of your health information, as may be necessary for you to receive follow-up care from us or another health professional.
  • The use and disclosure of your health information for the purposes of payment, including, but not limited to, providing this information to your insurance company, third party, billing agent or other vendor for eligibility, determination of benefits, processing claims and receiving payment.
  • We may have indirect treatment relationships with other organizations (such as laboratories and vendors) and may have to disclose personal health information for purposes of treatment, payment, or health care operations.
  • That support personnel employed by this professional practice or any affiliated agencies, vendors or companies, including the optical personnel will have access to your health information.
  • The payment of medical insurance benefits to Carol Logan, O.D., and Logan Eye Care, or other appointed agencies or parties who may accept assignment for services provided.

You have the right to restrict or revoke this consent in writing at any time unless we have already treated you, sought payment for our services, or performed health care operations in reliance upon our ability to use or disclose your health information in accordance with this consent. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI).

By signing below, you acknowledge that you have read and understand that above information and voluntarily consent to the statements herein.

MM slash DD slash YYYY

Dilated Eye Exam

Why do we dilate your eye?

Pupil dilation is extremely important, because it allows Dr. Logan to see all the way into the back of the eye. During a normal eye exam, the doctor will use a bright light and a lens to look into the eye, inspecting the health of the cornea, iris, and lens of the eye. However, the bright light causes the pupil to contract, making it difficult to see the back of the eye. The drops are necessary to open the pupils for a broad view of the retina, optic nerve and important blood vessels. The dilation is not only an important tool in diagnosing and documenting a multitude of eye diseases, but it can also reveal general health problems like hypertension (HBP). The dilation is considered part of the eye exam and not billed separately.

Would you like your eyes dilated today, for a more comprehensive component of my eye health records?(Required)

Refraction for glasses and/or contact lenses

During a refraction, the doctor puts the instrument called a phoroptor in front of your eyes and shows you a series of lens choices. He or she will then ask you which of the two lenses in each choice looks clearer. Based on your answers, your eye doctor will continue to fine-tune the lens power until reaching a final eyeglass prescription. The refraction determines your level of hyperopia (farsightedness), myopia (nearsightedness), astigmatism and presbyopia.

Unfortunately, Medicare considers this a routine test and therefore does not approve it, making it a non-covered service. Since Medicare doesn’t cover it, many commercial insurance companies follow suit and also consider it a non-covered service. Vision plans do cover the charge of the refraction.

Woud you like a a refraction today, for a more comprehensive component of my eye health records?(Required)
MM slash DD slash YYYY

Retinal (Fundus) Photography

During your eye examination, a highly specialized digital camera is used to capture images of the central and peripheral retina, optic disc, and macula. The images captured are used to aid Dr. Logan in monitoring the progression of certain eye conditions/diseases. Fundus photographs are used to document abnormalities associated with diabetic retinopathy, age-related macular degeneration (AMD), glaucoma, cranial nerves, etc.

The photographs become part of your permanent record and will be interpreted and reviewed with you during the exam by Dr. Logan. We will repeat the photographs yearly to document any changes that may occur

If you have a Vision Benefit Plan, the fee to include photos at your visit is $45.00. If you have medical insurance then the photos may be covered. We will review your coverage with you.

It is Dr. Logan’s recommendation that the eyes be photographed for thorough documentation of your eye health.

Would you like photographs of the eye as a more comprehensive component of my records.(Required)
MM slash DD slash YYYY

Eye Resources

  • Cataract Surgery
  • Eye Exams
  • How the Eye Works
  • Interactive Eye
  • Introduction to the Eye
  • Multifocal Intraocular Lens Implants

Contact Lenses

  • The Right Age for Contacts
  • Types of Contact Lenses

Lenses & Frames

  • Blue Light and Eye Health
  • Eyeglass Frame Materials
  • High Definition Lenses
  • No Glare Lenses
  • Progressive Lenses
  • Proper Lens Care Instructions
  • Protective Eyewear
  • Reduce Digital Eye Strain
  • Scratch Protection
  • Sunglasses
  • Thinner and Lighter Lenses

Eye & Health Disease

  • Blepharitis
  • Cataracts
  • Conjunctivitis
  • Diabetic Retinopathy
  • Dry Eye Syndrome
  • Eye Allergies
  • Glaucoma
  • Macular Degeneration
  • Retinal Tears and Detachments
  • Vision Therapy

Contact Us

  • 560 Rinehart Road
  • Suite 100
  • Lake Mary, FL
  • 32746
407-333-7333 407-333-7313 [email protected]
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