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Thank you for your patience as we adapt to new practice guidelines and new protocols in an effort to protect you and our staff. Check all our recommended COVID-19 protocol here.

Located inside LensCrafters at the Gateway Center Plaza just west of i95
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Call at 561-536-3249‬
Text Us at 561 536 3249
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Home » Contact Us » Patient Record

Patient Record

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  • RETINAL PHOTOGRAPHS ARE STRONGLY RECOMMENDED BY ALL EYE SPECIALISTS
    IF YOU HAVE NOT HAD AN EYE EXAM WITH A SPECIALIST IN THE PAST 6 MONTHS, THE DOCTOR WILL TAKE RETINAL PHOTOS OF YOUR EYES. THIS IS TO ASSESS THE HEALTH OF THE EYE MORE THOROUGHLY AND IT GOES HAND IN HAND WITH DILATION. YOUR INSURANCE COPAY FOR PHOTOS IS $39 or $45.
  • DILATION OF THE PUPILS: This is the only way to have a thorough and complete eye examination. Health problems such as glaucoma, cataracts, retinal degeneration or tears, diabetes, high blood pressure and some tumors may be detected even before the onset of symptoms or loss of vision. Dilation will temporarily result in blurred vision and sensitivity to light for about 2-4 hours.
  • I understand that there may be diseases, defects, lesions, or other problems of the eye or body associated or not associated with pain, vision loss, or other symptoms that were not examined or ruled out today; and as a result, I do not hold Stephanie Cortes O.D., Howell Cohen O.D., Cortes Eye Care, or their associates liable for any delay in diagnosis and treatment that may have resulted from my deferring dilation today. I understand that it is my or my guardian’s responsibility to reschedule this portion of the exam.
  • INSURANCE RECIPIENTS: I authorize the release of any medical or other information necessary to process my insurance claims. I also accept request of government benefits either to myself or to the party who accepts assignment, further authorizing payment of medical benefits to the undersigned physician or supplier for services rendered. I understand that my signature on this form will serve as a permanent signature on file and will be used for accept assignment purposes only.
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  • HIPAA ACKNOWLEDGMENT

    My signature confirms that I have been provided with a copy of the Notice of Privacy Practices (NPP) of Stephanie Cortes O.D. or Cortes Eye Care, and have been offered a copy of such policy to keep for my records.
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  • If you wish to view and/or download a copy of our Notice of Privacy Practices, please click here

  • PATIENT’S MEDICAL HISTORY QUESTIONNAIRE

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  • Patient’s Ocular History

  • (Please check yes for any conditions that are present in your or your family’s history)

  • Patient’s Social History

  • (strictly confidential, you may opt to leave this portion blank or discuss these items directly with the doctor)

  • Patient’s Review of Systems


  • Please check any current or past history

  • Patient Fees and Payment Policies


    We plan for your experience with Stephanie Cortes OD PA to be an excellent one. To further that goal, we want you to be fully informed about our fees and payment policies.

    PAYMENT
    • Payment will be collected prior to services rendered. If you are a contact lens wearer, contact lens fitting fees will be collected prior to you exiting the office. It is your responsibility to pay your current outstanding balance prior to exiting the office–this means should you need assistance please speak to staff on the doctor’s side or staff on Lenscrafters side.

    • No Refunds on services

    • All balances must be paid within 30 days of the invoice date. We will either mail or text you your outstanding invoice. Balances over 30 days may incur finance charges. It is your responsibility to give us a current address and phone number should we need to contact you.

    • A minimum administrative fee of $40.00 will be added to any unpaid balance that is over 30 days past invoice. Patient and/or Patient parent/guardian will be responsible for collection fees, if account balance is turned over for recovery.

    • We reserve the right to make changes to our fees and/or policies without advance notice.

    INSURANCE All charges incurred at our office are your responsibility, regardless of insurance coverage. You are responsible to know your coverage.
    • You are responsible for your co-pay at the time of service. Stephanie Cortes OD PA staff will submit, on your behalf, to your insurance company for reimbursement for services. You are responsible for all remaining deductible and coinsurance amounts.

      COMMUNICATION
      • Off Hours – An off hours number is available for contacting the doctor when he/she is not in the office, it is (561) 536-3249‬. There is a $70 fee for this service.
      • Texting — Texts are not received or reviewed on the clinic phone. Texts to your provider are never an appropriate form of communication, regarding either your own or another’s healthcare.
      • Email – Email correspondence is not appropriate for urgent medical needs! Emails are reviewed and responded to in the order in which they were received. Due to the high volume of emails, it may take up to 1 week, for your doctor to be able to respond. Email is not appropriate for new healthcare symptoms or concerns. If you have a medical concern or question, please schedule an appointment.

      CONTACT LENS EXAMS
      A contact lens fitting is NOT part of a routine eye exam so there is an additional fee. Prices for contact lens fittings range from $60 to $200. The contact lens fitting includes trial lenses, corneal topography, and corneal assessment to properly fit your contact lenses. The doctor may recommend a follow-up appointment. All fees are due at the time of service and they are non-refundable. You are responsible to return for your follow up appointment as determined by the doctor. If you fail to return for your follow up within 1 month, you may incur a $60 fee for your visit. After 3 months you will be charged for a new contact lens exam.
      • Contact Lens training: Only applies to first time Contact Lens wearers and is to be completed to the satisfaction of the doctor. The fees for Contact Lens Training are $20 each session. This is not covered by insurance


      CLINIC POLICIES

      CANCELLATION
      Stephanie Cortes OD PA requires 24 hours notice, received during normal business hours, for any established patients to cancel or change an appointment. Appointments cancelled with less than 24 hours notice or those missed entirely will be charged the $50 no show fee. This applies regardless of whether or when you received an email reminder.*

      I hereby state that I have read and will abide by the Patient fees and Payment policies as advised on this document.

      I hereby assign and authorize payment directly to the providers at the office of Cortes Eye Care, the medical/vision benefits to which I am entitled under my insurance policy(s). I understand that I am financially responsible to said clinic for charges not covered by this assignment. By receiving a service from Stephanie Cortes OD PA I am agreeing to pay for that service even if my insurance company denies payment.
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