Download Patient Registration Forms - Monte Vista Eye Care Center

MONTE VISTA EYE CARE
Paul W. Heersink, O.D.
REGISTRATION FORM
Today’s Date ______/______ /_______
PATIENT INFORMATION
Legal First Name______________________________ M.I. _____ Last Name ___________________________________
Date of Birth _____/_____ /_____
Age ______
Sex: □ Female □ Male
Marital Status: □ Single □ Married □ Other
Social Security # ______/______/_______
Mailing Address ______________________________________________________________
Home Phone ____________________________
City _____________________________________________ State _____ Zip _____________
Cell Phone ____________________________
Occupation ____________________________ Employer _________________________________ Work Phone ____________________________
Spouse’s Name ______________________________ If minor, parent(s)/guardian(s) names_____________________________________________
Emergency Contact ______________________________ Relationship _____________________ Telephone # ____________________________
RESPONSIBLE PARTY AND BILLING INFORMATION
Legal First Name______________________________ M.I. _____ Last Name ___________________________________
Date of Birth _____/_____ /_____ Social Security # ______/______/_______ Relationship to Patient ____________________________________
Mailing Address ______________________________________________________________
Home Phone ____________________________
City _____________________________________________ State _____ Zip _____________
Cell Phone _____________________________
Occupation ___________________________ Employer __________________________________ Work Phone _____________________________
INSURANCE INFORMATION
Vision Insurance
Primary _____________________________________ Policy Holder’s Name ____________________________ Date of Birth _____/_____ /_____
Member ID # ______________________________________ Group # _________________________
Medical Insurance
Primary ______________________________________________ Member ID # _____________________ Group # _________________________
Secondary ___________________________________________ Member ID # ______________________ Group # _________________________
STATEMENT OF PERMIT
I request that payment of authorized Medicare or other insurance carrier benefits be made on my behalf to Monte Vista Eye Care for
any services furnished to me by Dr. Paul W. Heersink. I authorize any holder of medical information about me be released to the Health
Care Finance Administration (Medicare) or any other insurance carrier that I have contracted with, or their agents, any information
needed to determine those benefits or the benefits payable for related services. I have received a copy of the Notice of Medical
Information Privacy Rights for Monte Vista Eye Care.
____________________________________________________
___________________________________
Patient’s Signature
Date
MONTE VISTA EYE CARE
Paul W. Heersink, O.D.
HEALTH HISTORY
Legal First Name_____________________________ M.I. ____ Last Name _____________________________ Date of Birth _____/_____ /_____
Name of Family Physician ___________________________________________
Telephone # _________________________
List allergies to medications: ________________________________________________________________________________________________
Current medications and reason for taking (attach medication list if needed): __________________________________________________________
________________________________________________________________________________________________________________________
List any major injuries, surgeries and/or hospitalizations you have had: ______________________________________________________________
________________________________________________________________________________________________________________________
Are you pregnant and/or nursing?
□ Yes □ No
Do you wear glasses?
□ Yes □ No If yes, how old is your present pair of lenses? __________
Do you wear contact lenses?
□ Yes □ No If yes, how old is your present pair of lenses? __________
If NO, are you interested in being fit with contact lenses today? □ Yes □ No
Type of contact lenses:
□ Rigid □ Soft □ Extended Wear □ Hybrid □ Scleral
Are they comfortable?
□ Yes □ No
Is there any specific reason or concern you are here for today? ____________________________________________________________________
Date of Last Eye Exam ________________ Name of Eye Doctor _______________________________Telephone # _________________________
Please check all conditions that apply to you and/or your family.
DISEASE/CONDITION
SELF
NO
YES
?
RELATIONSHIP TO YOU
Amblyopia (lazy eye)
Strabismus (turned eye)
Cataract
Glaucoma
Macular Degeneration
Retinal Detachment/Disease
Dry Eyes
Floaters / Spots / Flashing Lights
Headaches / Migraines
Cancer
Diabetes
Heart Disease
High Blood Pressure
Thyroid Disease
Other
Social History
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
Do you drive? □ Yes □ No
If yes, do you have visual difficulty when driving? □ Yes □ No
What do you do for recreation and leisure (hobbies)? _____________________________________________________________________________
Are you active in sports? If so, what type? _____________________________________________________________________________________
Do you use tobacco products?
□ Yes □ No If yes, type/amount/how long: ___________________________________________________
Do you drink alcohol products?
□ Yes □ No If yes, type/amount/how long: __________________________________________________
Do you use illegal drugs?
□ Yes □ No If yes, type/amount/how long: ___________________________________________________
MONTE VISTA EYE CARE
Paul W. Heersink, O.D.
FINANCIAL AGREEMENT AND OFFICE POLICY
Thank you for choosing Monte Vista Eye Care as your eye care provider. Our practice is committed to providing the best treatment for our patients.
In order to do so, the following is a statement of our financial agreement and office policy, which we require you to read and sign prior to any
treatment.
Insurance
All patients must supply us with insurance information, if applicable, before seeing the doctor.

CO-PAYMENTS AND/OR CO-INSURANCE CHARGES ARE DUE AT TIME OF SERVICE

We accept cash, checks, Visa, MasterCard, Discover and Care Credit.
We will bill your insurance company if we are an in-network provider with your carrier. You are responsible for any amount not covered by your
insurance. We can bill your insurance and provide accurate insurance coverage only if we are provided with current and accurate insurance
information. Your insurance policy is a contract between you, your employer and your insurance company. Please be aware that some, and perhaps
all, of the services provided may be non-covered services and not considered reasonable and necessary under your insurance program.
We will submit insurance claims once. If the claim is denied, it will be your responsibility to pay any remaining balance and resubmit the insurance
claim yourself.
If you are not using insurance coverage to cover your examination, all exam fees are due at the time of service. I understand that I am responsible for my
debt if my insurance company has not paid within 45 days. I understand that I am ultimately responsible for all expenses incurred for services provided regardless
of my insurance status. Any collection costs, attorney fees, court costs, or service fees incurred to collect on my account will be my responsibility.
A monthly rebilling charge of 2% will be assessed on all accounts with balances 60 days or older.
Past due accounts held for 90 days are subject to third party action.
Medical Exams and Insurance Claims
Only routine eye care may be covered by vision insurance.
All other medically necessary examinations (i.e., eye infection) should be covered under your medical insurance. It will be necessary to supply our
office with the appropriate information in order for us to submit any medical claims.
Please verify our participation with your insurance carrier prior to the examination.
Appointments
Any patient arriving fifteen minutes late for their scheduled appointment may be asked to reschedule their appointment. If you are running late or are
unable to make your appointment, please contact our office immediately.
There may be a charge for a missed office appointment. To avoid any charges, please give our office 24 hours notice when rescheduling or canceling
appointments.
Material Fees
All materials (spectacles, contact lenses, etc.) will require a minimum 50% deposit to be ordered and must be paid in full prior to being dispensed.
Some insurance companies require that you pay for materials in full before ordering.
Minor Patients
The adult accompanying a minor and the parents or guardians are responsible for all fees or the co-payment and/or co-insurance charges at the time
of rendered service. Please make the necessary arrangements for payment if a child is to be examined without a responsible adult present. For
unaccompanied minors, non-emergency treatment, other than routine eye examinations (i.e.-new contact lens fittings) will be denied unless charges
have been pre-authorized.
I have read the Monte Vista Eye Care Financial Agreement and Office Policy. I understand and agree to this Office Policy. I
agree to allow information regarding my eye examination to be released to my insurance company for claims processing. This
agreement will not require renewal.
____________________________________________________________
Patient Name (print)
____________________________________
____________________________________________________________
Signature of Patient or Responsible Party
________________________________________
Date
MONTE VISTA EYE CARE
Date of Birth
Paul W. Heersink, O.D.
NOTICE OF PRIVACY PRACTICES
This notice is effective on or after December 31, 2013
This notice describes how medical information about you may be used and disclosed and how you can obtain access to this information. Please
review carefully.
Uses and Disclosures
Treatment: Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating
you health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in
your medical record to all health professionals who may provide treatment or who may be consulted by staff members.
Payment: Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile
insurer, or from credit card companies that you may use to pay for such services. For example, your health plan may request and receive
information on dates of service, the services provided, and the medical condition being treated.
Health care operations: Your health information may be used to support date-to-day activities and management of Monte Vista Eye Care. For
example, information on the services you received may be used to support budgeting and financial reports, and activities to evaluate and promote
quality.
Law enforcement: Your health information may be disclosed to law enforcement agencies, without your permission, to support government
audits and inspections to facilitate law-enforcement investigations and to comply with government mandated reporting.
Public health reporting: Your health information may be disclosed to public health agencies as required by law. For example, we are required
to report certain communicable diseases to the state’s public health department.
Other uses and disclosures require your authorization: Disclosure of your health information or its use for any purpose other than those
listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you
may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or
disclosure of information that occurred before you notified us of your decision.
Additional uses of information
Appointment reminders: Your health information will be used by our staff to send you appointment reminders.
Information about treatments: Your health information may be used to send you information on the treatment and management of your
medical condition that you may find to be of interest. We may also send you information describing other health-related goods and services that
we believe may interest you.
Individual Rights
You have certain rights under the federal privacy standard. These include:
o The right to request restrictions on the use and disclosure of your protected health information
o The right to receive confidential communication concerning your medical condition and treatment
o The right to inspect and copy your protected health information
o The right to amend or submit corrections to your protected health information
o The right to receive an accounting of how and to whom your protected health information has been disclosed
o The right to receive a printed copy of this notice
Monte Vista Eye Care Duties
We are required by law to maintain the privacy of your protected health information and to provide you with this Notice of Privacy Practices. We
are required to abide by the privacy policies and practices that are outlined in this notice.
Right to revise privacy practices
As permitted by law, we reserve the right to amend or modify our privacy polices and practices. These changes in our policies and practices may
be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised
notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain.
Requests to inspect protected health information
As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may
obtain a form to request access to your records by contacting a receptionist, Sharon Lujan or Tabitha Valdez.
Complaints
If you believe that your privacy rights have been violated, you should call the concern/s to our attention by sending a letter describing the cause
of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint. If you would like to submit a
comment, question or complaint about our privacy practices, you can do so by sending a letter outlining your concern/s to:
Gina Garcia – Office Manager/Privacy Officer at Monte Vista Eye Care, 101 Chico Court, Suite B, Monte Vista, CO 81144 • 719/852-3412
MONTE VISTA EYE CARE
Paul W. Heersink, O.D.