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(407) 271-8931

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Patient Registration

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Eyeglass History

Contact Lens History

Annual contact lens evaluations are not included in a routine eye exam and are not usually covered by insurance. Therefore, payment will be required at the time of service for all new contact lens fittings and subsequent annual evaluations. The fee for the annual evaluation is based on the complexity and type of fit (ex: soft lens, toric, bifocal, RGP, etc.). The fee range is $95-$170. Please feel free to ask about how your benefit contributes to this fee.

Please skip if you do not wear contacts

Medical history

Optional Testing

1. DRS - Digital Retinography System: The newest technology in retinal screening. The DRS takes a digital picture of the retina, it allows the doctor to detect retinal problems such as macular degeneration, diabetic and hypertensive retinopathy, retinal holes, retinal detachments, and glaucoma. In most cases no dilation drops are needed. It is simple, quick and we can show you your image today. This provides a permanent record for your medical file that allows us to track and compare future images.

2. IWellness (OCT) measures retinal thickness and GCC thickness. This quick and simple test assists you in the early detection of many disorders such as glaucoma and retinal detachments.

3. Antioxidant Scanner: a cutting edge testing tool that non-invasively measures carotenoid levels in living tissue, providing an immediate indication of a person's overall antioxidant levels. This empowers individuals to make improvements to their diet and lifestyle, and helps them make an informed decision on which supplements are properly formulated to impact their antioxidant health.

Vision Insurance Policy

Please indicate vision provider information

Notice of Privacy Practice

This notice describes how your health informaiton may be used and disclosed. Please review it carefully.

1. At Southwest Orlando Eye Care, we have always kept your health information secure and confident.

2. A law requires us to continue maintaining your privacy, to give you this notice, and to follow the terms of this notice.

3. The law permits us to use or disclose your health information to those involved in your treatment. For example a review of your file by a specialist doctor whom we may involve in your care.

4. We may use or disclose your health information for payment of your services. For example, we may send a report of your progress to your insurance company.

5. We may use or disclose your health information for our normal healthcare operations. For example, one of your staff will enter your information into our computer.

6. We may use your information to contact you. For example, we may send newsletters or other information. We may also want to call and remind you about your appointments. If you are not home, we may leave this information on your answering machine or with the person who answers the call.

7. In an emergency, we may disclose your health information to a family member or another person responsible for your care.

8. We may release some or all of your health information when required by law.

9. You may request in writing that we not use or disclose your health information as described above.

10. As we will need to contact you from time to time, we will use whatever address, telephone numbers, or email address we have on file.

11. You have the right to transfer copies of your health information to another practice.

12. You have the right to see and receive a copy of your health information, with a few exceptions. Give us a written request or sign a records request form in regards to the information you are requesting.

13. If we change the details of this notice, we will notify you of the changes in writing.

14. You may file a complaint with the Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, Washington, D.C. 20201.

15. However, before filing a complaint, or for more information or assistance regarding you health information privacy, please contact our office at (407) 271-8931.


I have received a copy of the Southwest Orlando Eye Care Notice of Privacy Practices. Returns or cancellations of glasses or contacts are made at the discretion of this office. An in office credit will be issued. Progressive lenses have a non-adapt 90 day warranty, which means we can exchange the lenses for single vision or lined bifocal lenses. Ophthalmic lenses for glasses are custom made for you.

Financial and Insurance Policy

Thank you for choosing Southwest Orlando Eye Care as your Vision Care Provider. As a part of our services, we try to contain the ever-rising cost of vision care. In an effort to do so, we advise you to read and sign the following financial policy prior to treatment. Patient or responsible party must complete our information and insurance form before seeing Dr. John Nowell.

• FULL PAYMENT, CO-PAYMENT, PERCENTAGES AND/OR DEDUCTIBLES ARE DUE AT THE TIME SERVICES ARE RENDERED. We accept cash, checks, Visa, MasterCard, American Express, Discover. and Checks. If you are purchasing eye glasses or contacts, you will be expected to pay in full before any orders can be processed.

• No Show and Cancelations: We understand that situations arise in which you must cancel your appointment. It is therefore requested that if you must cancel your appointment you provide more than 24 hours notice. This will enable for another person who is waiting for an appointment to be scheduled in that appointment slot. With cancellations made less than 24 hours notice, we are unable to offer that slot to other people. Office appointments which are cancelled with less than 24 hours notification may be subject to a $35.00 cancellation fee. Patients who do not show up for their appointment without a call to cancel an appointment will be considered as NO SHOW. We understand that Special unavoidable circumstances may cause you to cancel within 24 hours. Our practice firmly believes that good physician/patient relationship is based upon understanding and good communication.

• 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 (the patient) will be notified. Returned or cancellations are made at the discretion of the office manager. Please make your selection carefully.

• Minor Patients (under the after 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. All returned checks will not be redeposited. 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 our collection agency. We request a copy of your driver’s license for your records if you wish to make payments by check.

• Spectacle Prescription: If the patient desires to take their spectacle lens prescription elsewhere, Southwest Orlando Eye Care will not be responsible for any warranty on glasses made elsewhere. However, the optician will be happy to check the prescription of your glasses against your prescription given by Dr. Nowell at no charge. If you are not happy with your eyeglasses purchase for any reason we will gladly refund your money within 60 days after you receive your eyeglasses. Frames come with a one year warranty.

• Contact Lens Patients: Additional time and testing is required for the fitting and evaluation for contact lenses so there will be an additional professional fee charged outside of the comprehensive examination fee. Patients have 60 days of follow-up care from the date of the fitting to make any changes in the prescription necessary, any visit after 60 days, a fee will be incurred. A contact lens prescription is only valid one year from the exam date and cannot be filled once expired. Once contacts have been ordered and received by the patient, contact lenses cannot be returned. If the patient desires to take their contact lens prescription elsewhere, Southwest Orlando Eye Care will not be responsible for any warranty on their contact lenses, and all follow-up visits will be charged an additional professional fee.

• Eyeglass and contact lens prescriptions (when requested) are faxed at the end of each business day.

Please acknowledge that:

1. Your insurance is a contract between you, your employer, and the insurance company. We are not a party in that contract.

2. You are responsible for all charges that are denied/not covered by the insurance company. Not all services are covered under.

3. Although we verify coverage through your insurance company with each and every patient, verification of benefits is not a guarantee of payment. You must present a company of your insurance card for your records if insurance or any discount plans are being utilize. Only one insurance/discount plan is accepted, per patient, per year.

• I authorize release of any information concerning my healthcare and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I hereby authorize payment of insurance benefits directly to the Optometrist, otherwise payable to me.

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