PLEASE TELL STAFF IF YOU ARE USING A VISION PLAN - THIS IS VERY IMPORTANT. IF THIS IS NOT INDICATED, YOU MAY BE RESPONSIBLE FOR ALL CHARGES!!
A COMPLETE eye exam includes the use of drops to dilate your pupils. Dilation usually causes blurred vision. Some
people find driving very difficult following dilation. We strongly suggest you do not drive until you are
comfortable doing so. If you wish, you may return for a second visit at no charge (within 90 days) for dilation. If
you choose to drive yourself, you acknowledge that you understand the risks and accept full responsibility for
injuries to yourself or others. In addition, we strongly suggest you use sunglasses to reduce your increased
sensitivity to light while driving. We will provide shades to you at no charge if requested.
Your signature below indicates that you have been warned of the potential risks that dilating eye drops may have on
your ability to drive.
I request that payment of authorized Medicare, Medigap or any other insurance benefits be made either to me or on my
behalf to KALIN EYE ASSOCIATES for any services furnished me by its physicians.
It is understood that the responsibility for all charges remains with the patient. Additionally payment is to be
made at the time or service for amount not paid by insurance.
I authorize any holder of medical information about me to release to all my insurance companies or to the Health
Care Financing Administration and its agents any information needed to determine these benefits payable for related
I permit a copy of this authorization to be used in place of the original.
I have received a copy of the notice of privacy practices.
PATIENT PORTAL: To view a summary of your records, visit Kalineye.com and click on the Patient Portal link on the homepage. You will need to register and enter your information exactly as it is listed with the office. Your SS# is needed. The initial password is Kalineye. Login with your email. It may take up to 72 hours for your information to be posted.
We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.