Download Patient and Privacy Form 2014

Welcome to Our Office
Please fill in the following information to help us provide you with optimum care:
Today's Date
Date of Birth
Last Name
SS#
Address:
Home Phone
M/F
Age
First Name
MI
Spouse or Guardian :
City
State
Work Phone
Zip Code
Cell Phone:
Occupation:
Email address:
Preferred Language
Race
Ethnicity
Emergency Contact: Name:
Relationship:
Phone:
How did you hear about our office? Friend/family member (name)
Yellow Pages  Internet site  Insurance Plan  Other Referral
Patient Medical and Eye History
What health concerns or problems do you have regarding your eyes today? (Circle all that apply)
Dryness
Pain
Redness
Itch
Lid Droop
Watery
Light Sensitivity
Glare
Blur
Strain
Irritation
Haze
Family History of Eye Disease
Other___________________________________________________________________________________________
Date of last eye exam____________________ By whom? ________________________________________________
Do you currently wear contact lenses?
 No Yes Type: ______________________________________________
Have you ever been diagnosed with or treated for the following? (Circle all that apply)
Cataracts
Corneal Abrasion
Dry Eye
Eye Injury
Iritis/Uveitis
Macular Degeneration
Lazy Eye
Retinal Detachment Eye Infection
Eye Allergies
Diabetic Eye Disease Glaucoma
Other Eye Disorders (list)______________________________________________________________________________________
CURRENT MEDICATIONS (Rx or over the counter) List medications including eye drops, vitamins & contraceptives.
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Allergies to medication: (please list) ___________________________________________________________________________
Are you currently pregnant or nursing? _______
Are you a smoker? ______ pk/day
Drink alcohol? _______ drinks / day
Have you ever been diagnosed with or treated for the following? (Circle all that apply)
Allergies
Anemia
Arthritis
Asthma
Epilepsy
Developmental Disabilities
Heart Disease
Fibromyalgia
Colitis
Depression
Diabetes
Panic/Anxiety Disorder
Thyroid
Leukemia
Lupus
Weight Loss
High Blood Pressure
Muscular Dystrophy
Multiple Sclerosis Cancer (type) ______________________________________________________________________________
Name of family physician/practitioner: ______________________________________ Date of Last Visit ______________
Family Medical and Eye Health History
Please circle all the following medical health conditions that have occurred in your family:
Cataracts
Corneal Problems
Diabetes
Macular Degeneration
Heart Disease
High Blood Pressure
Glaucoma
Retinal Detachment/Disease
Other _____________________________________________________________________________________________________
1/2014
Financial Policy / Insurance Information
We ask that all patients read and sign our Financial Policy prior to seeing the doctor.
1.Payments and all co-payments are due at the time of service. Please indicate your preferred method of payment
today.
 Check / Cash  MasterCard / VISA  American Express  Discover Card
2.With insurances that require a referral, our office must have the referral prior to the appointment, or you will be charged
for the exam at the time of service. We will assist you in obtaining the referral or authorization needed for services, but
a referral or authorization, once obtained, does not guarantee payment to this office. You will be responsible for all
charges that are not covered by your insurance due to co-payments or deductibles.
3.There are no refunds for examinations / treatment services or material purchases.
4.There will be a $30.00 fee for all returned checks, and balances older than 45 days may be subject to additional
collection fees and interest.
About Your Insurance
There are two types of health insurance that will help pay for your eye care services and products. You may have both
and our practice accepts both:
1. Vision Care plans (such as VSP, Davis, Spectera, Avesis, etc)
2. Medical insurance (such as Blue Cross Blue Shield, Presbyterian, Lovelace and Medicare)
 Vision care plans only cover routine vision exams along with eyeglasses and contact lenses. Vision plans
over a basic screening for eye disease. They do not cover diagnosis, management or treatment of eye diseases.
 Medical insurance must be used if you have any eye health problem or systemic health problem that is
associated with ocular complications. Your doctor will determine if these conditions apply to you, bust some
are determined by your case history.
 If you have both types of insurance plans it may be necessary for us to bill some services to one plan and
other services to the other. We will use coordination of benefits to do this properly and to minimize your outof-pocket expense.
 We will bill your insurance plan for services if we are a participating provider for that plan. We will try to
obtain advanced authorization of your insurance benefits so we can tell you what is covered. If some fees are
not paid by your plan, we will bill you for any unpaid deductibles, co-pay or non-covered services as allowed
by the insurance contract.
I, the undersigned, have read and agree to the above policies.
Signature:
Patient (Parent or Guardian if minor)
Medical Insurance:
Date:
Vision Insurance:
Assignment and Release: I hereby authorize third party or insurance payments to be made directly to Accent on Vision
and fully understand that I am the responsible party for all fees incurred by me at the above mentioned facility. I also
authorize the release of any information required for the processing of those claims.
I, the undersigned, have read and agree to the above policies.
Patient’s signature
Date
Reviewed: signature:
Date:
BRING YOUR INSURANCE CARD TO THE FRONT DESK
If you are a new patient seeing us for a medical eye problem, we need a copy of your insurance card prior to your visit. If
do not have it with you, we can reschedule your appointment or you can handle the fees personally today
1/2014
Practice’s Requirements
The Practice:
(a)
Is required by federal law to maintain the privacy of your PHI and to
provide you with this Privacy Notice detailing the Practice’s legal duties and privacy
practices with respect to your PHI.
(b)
Under the Privacy Rule, may be required by State law to grant greater
access or maintain greater restrictions on the use or release of your PHI than that which is
provided for under federal law.
(c)
Is required to abide by the terms of this Privacy Notice.
(d)
Reserves the right to change the terms of this Privacy Notice and to make
the new Privacy Notice provisions effective for all of your PHI that it maintains.
(e)
Will distribute any revised Privacy Notice to you prior to implementation.
(f)
Will not retaliate against you for filing a complaint.
Effective Date
This Notice is in effect as of 04/15/03.
PATIENT ACKNOWLEDGEMENT
By subscribing my name below, I acknowledge receipt of a copy of this
Notice, and my understanding and my agreement to its terms.
_____________________________
Patient
Date
1/2014
1/2014