New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. Miss Master

Address:
City:		State/ZipCode	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	Dr. Kye, Mansfield Dr. Rena, Lewis Dr. Dr. Victoria	Misc/Guardian
How Did You Hear About Us?	doctor friend/family insurance internet sign/location

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Miss Master

Address

City	State	ZipCode
	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None New Insurance New Insurance New Insurance AARP/United Healthcare AEA Teacher Discount Aetna Aetna Senior Supplemental Allied Health Benefits, Inc. Alternative Insurance Resources/Global Care, Ince Atlanta United Healthcare Avesis Avesis Blue Cross Blue Shield BrightHealth BrightHealth Medicare Advantage Care Credit Champ VA Cigna Colonial Penn Insurance Commercial CPNF Credit Bureau of Bessemer, INC Davis Vision Plan Disability DOM Vision Plan Eyemed Vision Care Freedom Life Insurance Company of America Gilsbar, L.L.C Golden Rule Golden Rule Golden Rule Health Spring HealthPartners HealthSCOPE Benefits Humana Lucent Health Lucent Health Lunovus ManhattanLife Assurance Medi-Share Medicaid 1437659745 MEDICARE 'DMERC' REGION C Medicare H080 Need New Insurance New InsuranceA New Southland NIPP NONE NVA/ National Vision Administrators, LLC Opticare Physical Mutual Railroad Medicare H080 Replacement Glasses Ryder Safety Special Insurance Service Inc. Spectera Vision State Employee Premium Superior Vision Services Tricare East Region UMR UMWA Health and Retirement Funds United HealthCare VA CCN OPTUM VCP standard Vision First Co-Management VIVA VIVA Medicare Plus VSP Workman's Comp
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information

Insurance Name:	None New Insurance New Insurance New Insurance AARP/United Healthcare AEA Teacher Discount Aetna Aetna Senior Supplemental Allied Health Benefits, Inc. Alternative Insurance Resources/Global Care, Ince Atlanta United Healthcare Avesis Avesis Blue Cross Blue Shield BrightHealth BrightHealth Medicare Advantage Care Credit Champ VA Cigna Colonial Penn Insurance Commercial CPNF Credit Bureau of Bessemer, INC Davis Vision Plan Disability DOM Vision Plan Eyemed Vision Care Freedom Life Insurance Company of America Gilsbar, L.L.C Golden Rule Golden Rule Golden Rule Health Spring HealthPartners HealthSCOPE Benefits Humana Lucent Health Lucent Health Lunovus ManhattanLife Assurance Medi-Share Medicaid 1437659745 MEDICARE 'DMERC' REGION C Medicare H080 Need New Insurance New InsuranceA New Southland NIPP NONE NVA/ National Vision Administrators, LLC Opticare Physical Mutual Railroad Medicare H080 Replacement Glasses Ryder Safety Special Insurance Service Inc. Spectera Vision State Employee Premium Superior Vision Services Tricare East Region UMR UMWA Health and Retirement Funds United HealthCare VA CCN OPTUM VCP standard Vision First Co-Management VIVA VIVA Medicare Plus VSP Workman's Comp
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Referring Physician:	Adams, Michael Aizenman, David Albert, Michael Alred, Ginger Blackburn, Vance Cogen, Martin Collins, Clagett Cotter, Clement Counce, Diane Eslami, Nasrollah Feist, Richard Girkin, Christopher Halvorson, David Hays, Sarah Howard, Gary Johnson, Carol Joiner, Wade Mason, John McClelland, Bryan Michaelson, Marc Morris, Robert Nolen, Thomas Pfister, Roswell Remillard, Michael Rock, Karin Rudeseal, Frank Snyder, Robert Thomley, Martin Vaphiades, Michael Vicinanzo, Matthew Walker, Sara Walters, Cynthia Witherspoon, Doug Wofley, Darrell Yunker, Jacob Other	Phone #:
Primary Care Physician:	Aizenman, David Alred, Ginger Blackburn, Vance Collins, Clagett Cogen, Martin Counce, Diane Howard, Gary Johnson, Carol McClelland, Bryan Nolen, Thomas Remillard, Michael Rock, Karin Rudeseal, Frank Snyder, Robert Walker, Sara Walters, Cynthia Other	Phone #:

Eye History

Do You Have History Of Any Of The Following?

	Blindness		Cataracts
	Double VA		Dry Eyes
	Eyes Burn, Itch And Water		Eye Infection Or Disease
	Eye Injury		Eye Strain
	Eye Surgery		Floaters Or Spots
	Glaucoma		Macular Degeneration
	Retinal Disease		Severe Pain
	Turned Or Lazy Eyes		Diabetes

Date of last eye exam and where?		Do you wear contact lenses?	Yes No
Brand if known		Are you interested in contact lenses?	Yes No

Medical History

Medications:	Allergies

Hearing Loss:	Yes	No
Arthritis:	Yes	No
Lupus:	Yes	No
Sjogren's	Yes	No
Sexually Transmitted Disease:	Yes	No

Other:

Hypertension? Yes No

Height FT IN

Social History

Preferred Language

(declined) English Spanish Other

Race	(declined) America Indian or Alaska native Asian Black or African American Native Hawaiian or Pacific Islander White Other

Ethnicity

(declined) Hispanic or Latino Not Hispanic or Latino Other

Family History

	Diabetes		Cataracts
	Blindness		Glaucoma
	Turned Or Lazy Eyes		Macular Degeneration
	Retinal Detachment

Family Members Living At Home:

Name:
Name:
Name:

Review Of Systems

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

General:	Fever	Weight Loss / Gain	Fatigue
Ear, Nose, Throat:	Allergies	Sinus	Cough	Dry Mouth / Throat
Cardiovascular:	High Blood Pressure	Heart Conditions	Vascular Disease	Stroke
Respiratory:	Asthma	Bronchitis	Emphysema	COPD
Genital, Kidney, Bladder:	Kidney Stones	Frequent Urination	Impotence	Menopause
Muscle, Bones, Joints:	Arthritis	Joint Pains	Head Or Neck Injury
Skin:	Growths	Rashes	Acne
Neurological:	Headaches	Migraines	Seizures	Dizziness	Double VA
Psychiatric:	Depression	Anxiety	Insomnia
Endocrine:	Thyroid	Diabetes	Vitamin Deficiency
Blood / Lymph:	Anemia	Chol	Bleeding Problems
Allergic / Immunologic:	Seasonal Allergies	AIDS	Allergy Shots
Gastrointestinal:	Diarrhea	Constipation	Ulcer	Reflux

Social History

Do You Drink Alcohol? Yes No    If Yes, How Many Drinks Per Day?

Smoking Status Current every day smoker Current some day smoker (not daily) Former smoker (no longer smokes) Heavy smoker (>10 cigs/day) Light smoker (<10 cigs/day) Never smoker (<100 cigs equiv) Smoker (current status unknown) Unknown if ever smoked Other

Do You use Recreational Drugs? Yes No

Are You Pregnant? Yes No

Do You Have Any STD's? Yes No

Submit Data / Patient Signature

Notice of Privacy Practices

I understand that in an attempt to protect the privacy of my identifiable health information, Kye Mansfield, O.D. has established a Privacy Policy and guideline for Privacy Practices within their office. This information details the use and/or disclosure of information contained in my personal medical/optometric records kept for purposes of diagnosis, treatment, payment and health care operations. In accordance with HIPAA Regulations, a copy of the Kye Mansfield, O.D. Privacy Policy and Practices has been made available to me while in the office today. Should I choose to have a personal copy; one will be given to me at no charge.

I have read, understand and acknowledge the Privacy Policy and Practices of Kye Mansfield, O.D.
I have elected not to read the Privacy Policy and Practices of Kye Mansfield, O.D.
A copy of the Privacy Policy and Practices of Kye Mansfield, O.D. was given to me today as I requested.

Authorization for Release of Identifying Health Information

I authorize the office of Kye Mansfield, O.D., to release health information identifying me under the following terms and conditions:

	Myself only
	Family Members, please specify
	Doctors, please specify
	To whom the Physician sees fit
	Other, please specify

It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you if you choose not to sign this authorization.

I do not wish to have my name used while in this office; I agree to notify the front desk to be addressed as a number per HIPAA guidelines.

CONSENT FOR TREATMENT/FINANCIAL AGREEMENT: I CONSENT TO TREATMENT NECESSARY OR DESIREABLE TO THE CARE OF THE PATIENT FIRST MENTIONED ABOVE, INCLUDING BUT NOT RESTRICTED TO, WHATEVER DRUGS, MEDICINE, PERFORMANCE OF OPERATION

THAT MAY BE USED BY THE ATTENDING DOCTOR, HER TECHNICIAN, OR QUALIFIED DESIGNATE. I ALSO ACKNOWLEDGE FULL RESPONSIBILITY FOR THE PAYMENT OF SERVICES ON THE DAY OF VISIT. I UNDERSTAND THAT THE PATIENT OR RESPONSIBLE PARTY IS SOLELY RESPONSIBLE FOR PAYMENT OF ALL SERVICES, THOUGH THE INSURANCE MAY BE FILED. IF THIS ACCOUNT BECOMES OVERDUE I AGREE TO PAY ALL COSTS OF COLLECTION, INCLUDING A REASONABLE ATTORNEY'S FEE Initials

I UNDERSTAND THAT SOME SERVICES MAY NOT BE COVERED BY MY INSURANCE COMPANY BASED ON THE MEDICAL NECESSITY AND IF ANY TREATMENT IS REJECTED BY MY INSURANCE PLAN AS A NONCOVERED PROCEDURE, I WILL BE BILLED FOR THOSE SERVICES. I ALSO ACKNOWLEDGE AS A MEMBER OF THESE PLANS, THAT THIS OFFICE WILL SUBMIT MY INSURANCE AND I WILL BE RESPONSIBLE FOR PAYING ALL COPAYS AND/OR DEDUCTIBLES AT THE TIME OF VISIT. Initials

I UNDERSTAND THAT IF MY INSURANCE IS AN HMO, THAT I AM RESPONSIBLE FOR OBTAINING A REFERRAL FROM MY PRIMARY CARE DOCTOR PRIOR TO MY APPOINTMENT. I UNDERSTAND THAT IT IS MY RESPONSIBILITY AS THE PATIENT TO CONFIRM THAT MY REFERRAL IS CURRENT AND IN EFFECT WHEN I ARRIVE FOR MY APPOINTMENT. IF NO REFERRAL IS OBTAINED, I WILL PAY FOR THE VISIT. Initials

I AUTHORIZE MY INSURANCE COMPANY TO REMIT PAYMENT OF MEDICAL BENEFITS DIRECTLY TO THIS OFFICE FOR SERVICES PROVIDED BY OUR PHYSICIANS. Initials

I UNDERSTAND THAT SHOULD MY ACCOUNT BECOME OVERDUE, EACH STATEMENT AFTER 120 DAYS WILL HAVE A $5.00 FEE APPLIED. Initials

Policy for Eyewear Purchases

WE STRIVE TO PROVIDE YOU WITH EXCELLENT EYECARE AND EYEWEAR. IF YOU ARE DISSATISFIED WITH YOUR EYEWEAR WITHIN 30 DAYS OF ORIGINAL PURCHASE DATE, YOU MAY SELECT A DIFFERENT FRAME (OF EQUAL OR LESSER VALUE AT NO ADDITIONAL CHARGE; ANY UPGRADE IN PRODUCT WILL BE SUPPLIED WITH ADDITIONAL COST) .WE WILL REMAKE YOUR LENSES ONE TIME AT NO ADDITIONAL CHARGE IN THE 30 DAY PERIOD. SHOULD YOU DESIRE TO RETURN YOUR EYEGLASSES, YOU WILL RECEIVE AN IN HOUSE CREDIT APPLIED TO YOUR ACCOUNT. THERE IS A $50 RESTOCKING FEE FOR THE FRAME. LENSES THAT HAVE BEEN VERIFIED AS CORRECT ARE NON RETURNABLE. PURCHASES MADE USING VISION PLANS ARE NOT ELIGIBLE FOR CREDIT.

Signature: Date:

Optomap Retinal Exam The Optomap Retinal Exam provides us with a scan of the retina to confirm the health of your eye and allows our doctors to detect the presence of disease early in its progression. Your Optomap image will be saved in your medical file enabling your doctor to make important comparisons during your annual eye exams. It may not require dilation drops which result in blurred vision and sensitivity to light for several hours. Some patients will need to have their eyes dilated also. The fee for the Optomap Retinal Exam is $39.00 and is not covered by your insurance. Our doctors recommend you have this test done at your annual exam.

Yes, I would like an Optomap performed today and I understand that I still may have to be dilated at the doctor’s discretion.

Unsure, Please tell me more.

No, I decline and understand that using the Optomap greatly enhances my doctor’s ability to comprehensively examine your eyes. I understand that early detection of potentially threatening disease is an important part of my thorough eye health evaluation. I am prepared to have my pupils dilated today.

Signature: Date: