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(713) 349-9292

Welcome to Envision Eye Care!

Contact Information

Your phone number and other contact information will ONLY be used for verifying insurance, appointment reminders, and order updates. No marketing or any form of advertising will be sent.

Vision Insurance Information

Complete address and primary information are required for accurate insurance billing.

Medical Insurance Information

Please present applicable insurance cards to staff. Complete address and primary information are required for accurate insurance billing.

Exam History

Please Note Family History for the Following:

General Eye History

General Medical History

The cost of this screening is included in the price of the exam. The dilation drops enlarge the size of the pupil (the central dark spot of the eye), which allows Dr. Nguyen to examine the retina (back of the eye) for signs of disease. The side effects are increased sensitivity to light that lasts for 4-6 hours and difficulty focusing up close for 2-3 hours. The doctor strongly recommends a yearly dilation as part of a comprehensive eye exam.

This screening may not be covered by insurance. Retinal photography assists in the early detection and management of serious problems such as glaucoma, optic nerve disease, diabetic retinopathy, and retinal holes or degeneration. We especially recommend this test for patients with a history of high blood pressure, diabetes, elevated cholesterol, retinal diseases, floaters, or headaches.

This screening may not be covered by insurance. Optical coherence tomography (OCT) is a non-invasive imaging test that uses light waves to take cross-section pictures of your retina, the light-sensitive tissue lining the back of the eye.With OCT, each of the retina’s distinctive layers can be seen, allowing Dr. Nguyen to map and measure their thickness. These measurements help with diagnosis and provide treatment guidance for glaucoma and retinal diseases, such as age-related macular degeneration and diabetic eye disease.

This screening may not be covered by insurance. The Visual Field Analyzer screens for loss of sight in your peripheral and central vision: due to diseases such as glaucoma, pituitary tumors, cataracts, retinal and macular detachments, and visual disturbances due to retinal and neurological diseases.

Any personal information given will only be used in verifying insurance and managing medical information; not for any marketing purposes whatsoever.

Assignment of Benefits/Insurance Agreement:

By dispensing the above information, I have authorized this vision care provider to release to the Health Care Financing Administration and its agents any information necessary to apply for benefits on my behalf for covered services. I also assign my benefit and request all payment from my insurance directly to my vision care provider. I authorize this vision care provider to release to the insurance any information to any related claim.

HIPAA Compliancy:

I acknowledge that a copy of the Notice of Privacy Practices (HIPAA) for the office will be available in person at the time of my exam. I have read and understand the terms and conditions outlined above, and I hereby verify that all the information provided is true and accurate to the best of my knowledge and understanding.

I have read all the above and agree to be liable for payments on all services rendered.

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