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Patient Forms

Please fill out the appropriate forms to take with you to your visit. Thank You.

All Patients New or Previous: Please complete the  Medical History Form and sign both lines of the Assignment and Release Form.


Medicare Patients


Non-Medicare Patients


Office Patients

Attention Medicare Patients:

According to CMS Centers for Medicare and Medicaid Services February 2011 Optometry Billing Guide:


Eye Examinations and Refractions


Eye examinations for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive errors are not covered. Expenses for all refractive procedures, whether performed by an ophthalmologist or an optometrist and without regard to the reason for performance of the refraction, are excluded from coverage. NHIC will deny vision services reported with ICD-10-CM diagnosis codes 367.0 through 367.9 (disorders of refraction and accommodation) as routine eye exams.


NHIC, Corp. page 28 February 2011

REF-EDO-0015 Version 4.0


The Refraction is the part of the eye exam that determines your eyeglass prescription. This is not covered by Medicare. This service is $49.00 this will be due at the end of your exam.

With any concerns or questions regarding this please contact Medicare at:


1-800-MEDICARE (1-800-633-4227)


Thank You
Fall River Vision

Attention Non-Medicare Patients:


Fall River Vision performs Retinal Imaging on all patients. Some insurance companies do not cover this charge. Patients are given the option to pay out of pocket, bill their insurance or refuse this service. Please read and complete the Commercial ABN Imaging Form above regardless of which choice you decide is best.


Retinal Imaging is used to identify many eye diseases. Many eye problems can develop without warning and progress with no symptoms. Early on, you may not even notice any change in your vision. However, diseases such as macular degeneration, glaucoma, retinal tears or detachments, as well as other health problems such as diabetes and high blood pressure can be detected early with a thorough examination of the retina.  By taking detailed images of each eye, this non-invasive procedure allows Dr. Posner to see a much broader and more detailed view of the retina than is possible with conventional methods.

Dr. Posner strongly recommends this procedure.


Reason Insurance May Not Pay


Fundus Photography is performed to evaluate abnormalities in the fundus, follow the progress of a disease, and plan the treatment for a disease. They are also performed when the information garnered from the eye exam is insufficient to adequately assess the patient disease. The images are taken as a baseline documentation of a healthy eye or as preventative medicine screen for potential disease.  Your insurance may not cover this charge when preformed as a preventative screening, or when you have a deductible that has not been fulfilled.

Office Visits and HMO's


Most office visits and some eye examinations require a referral from the patient’s primary care physicians. It is each patient’s responsibility to obtain any necessary insurance requirement such as referrals prior to any visit.


Please sign the above referral form if being seen for any visit that requires a referral. If a referral is not obtained before the appointment, the patient understands they will assume all financial responsibility for the visit.

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