Online Patient Form

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After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Patient Information


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Cell Phone:
Other Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Employer / School Name Misc/Guardian

Billing Information

Is The Billing Address the Same?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:

Primary Vision

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Vision

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Primary Medical

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Medical

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
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!

Personal Medical History

Reason for Visit: Secondary Reasons:

Vitamins: Over The Counter Medications:
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing:


Interested in contact lens evaluation?: Interested in LASIK?:


Do you have any of the following issues/conditions?:

Family Medical History

Unknown family history

Does anyone in your family have any of the following issues/conditions?:

Eye History

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Last Eye Exam: By Doctor:

Primary Vision Correction:
Do you:    Have back up glasses? Want new glasses?

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time:

Family Eye History

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:

Review of Systems

General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Musculoskeletal:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genitourinary:
Immune:

Social History

STD's:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long

Submit Form / Patient Signatures



NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

The full Notices of Privacy Practices of Eye Capitol, P.A. is available by request from our check-in desk, and is also available online at www.eyecapitol.com

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly or indirectly.

  • Obtain payment from third-party payers.

  • Conduct normal healthcare operations such as quality assessments and physician certifications.


I have read and understood the Notice of Privacy Practices of Eye Capitol, P.A., which contain a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of privacy Practices at any time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Signature: Date:

Signing this section is REQUIRED of all patients before services or treatments are performed

  • I understand that payment for services is due in full at the time services are rendered.

  • If ordering glasses or contact lenses, the full payment is expected at the time of ordering.


For patients using insurance:

  • I request that payment from my third-party insurer be made to Eye Capitol for any services or products furnished to me by this provider.

  • I authorize Eye Capitol to release any personal or medical information to any medical insurance, vision plan company, or its agents that is necessary for determining my benefits or collecting payment for services rendered.

  • I understand that I am responsible for any copays, deductibles, and co-insurance amounts after services have been rendered today or materials not covered by my insurance. It is ultimately my responsibility to know my insurance benefits and coverage.

  • I understand that Eye Capitol will act as my agent in filing my insurance. However, if payment is not received after a reasonable attempt at collecting from my insurance carrier, then I am ultimately responsible for any charges not covered by my insurance company.

  • I understand that vision plans only provide coverage for routine eye examinations and discounts on glasses and contacts. I also understand that vision plans do not cover for any medical eye problems that I am having.

  • I understand that my medical insurance will be billed today if I am having any medical eye problem as determined by the doctor, and that I am responsible for any and all deductibles, copayments, and coinsurance amounts under the terms of my medical plan.


Signature: Date:

OPTOMAP & DILATION FORM

**IMPORTANT PLEASE READ THOROUGHLY**

DUE TO CHANGES IMPLEMENTED TO PREVENT THE SPREAD OF COVID-19 WE WILL BE REQUIRING ALL PATIENTS WHO WISH TO RECEIVE A COMPREHENSIVE RETINAL EVALUATION DO SO BY MEANS OF OPTOMAP DIGITAL IMAGING. NOTE THIS DOES INCUR AN ADDITIONAL $39 FEE. THOUGH IT IS NOT RECOMMENDED, THESE SCANS MAY ALSO BE DECLINED. DILATING DROPS WILL ONLY BE USED ON A CASE BY CASE BASIS. NOTE THESE CHANGES ARE IN PLACE TO MAXIMIZE EFFICIENCY AND PREVENT THE SPREAD OF COVID-19 THROUGHOUT THIS TIME.

BELOW IS INFORMATION REGARDING THESE SCANS.

A comprehensive eye evaluation includes a thorough examination of your retinal health. This is the tissue that outlines the inside of your eyes. The Optomap uses a digital imaging system to record a detailed view of the retina. These images assist in the detection and management of retinal diseases, retinal detachments, tumors, and other eye conditions. It is especially important for those with a history of diabetes, high blood pressure, retinal diseases, flashing lights, decreased vision, or a strong glasses prescription. These images also provide an excellent reference point for future comparisons.

I elect to have the Optomap retinal scan for an additional $39 fee.

I am declining to have retinal health evaluated with the Optomap imaging at this time*

*I have been informed of the benefits of a thorough retinal exam and I understand that many conditions such as retinal diseases, retinal detachments, and malignant tumors may remain undetected without one. All of these conditions can lead to loss of vision, blindness or even death*

Signature: Date:

CONTACT LENS AND CORNEAL HEALTH EVALUATION

Contact lenses are medical devices that are regulated by the FDA and must be used and cared for properly. As a contact lens wearer, additional tests are performed that are necessary to make sure your eyes are healthy, that your lenses fit properly, and to ensure that you are seeing as well as possible. Contact lens professional fees are for the extra testing and time taken by the staff and doctor each year to properly evaluate your contact lenses.

Additional tests involved in contact lens evaluations:

Biomicroscopy: An ocular microscope is used to examine the fit of the contact lenses and the health of the cornea.
Corneal Topography: A digital mapping of your cornea to screen for disease and to monitor for undesirable changes caused by contact lens wear.
Specular Microscopy: A scan of the innermost layer of the cornea where changes may occur with reduced oxygen levels due to contact lens wear.
Contact Lens Refraction: Prescription measurements are taken which are different than those for eyeglasses.

Note: Fitting fees also cover a pair of prescription trial lenses and 60 days of follow-up care. If you elect to forego the follow-up care and return beyond the initial 60 day period, an additional visit will be charged ($50). Fitting fees do not cover the cost of contact lens materials. Fitting fees cannot be refunded.

The contact lens fitting fees are as follows:

Single vision sphere (non-astigmatism): $75.00
Single vision astigmatism: $85.00
Multifocal or monovision (presbyopia): $95.00
Specialty Contact Lens Fittings: $150.00 & up
These would include: keratoconus contacts, gas permeable lenses, scleral contact lenses
Training for 1st time contact lens wearers: $15.00

Contact lens services are separate procedures that may not be covered by your insurance. However, some vision plans provide an annual allowance that may be used toward the cost of contact lenses or contact lens service fees. In other cases, insurance may not cover contact lenses at all. Our staff will help you maximize your insurance benefits.

I have read and understand the above information and acknowledge that any fees not covered by my insurance will be my responsibility and must be paid at the time of service.

Signature: Date:

  • Please arrive 15 minutes before your appointment. This allows us to complete or update your patient information and ensures that you will receive the fully allotted time for your appointment.

  • A patient is considered late when they arrive after their scheduled appointment time. If you arrive late for your appointment, we will try to work you into the next available time, but other patients who have arrived on time for their appointments may see the provider first.

  • If you cannot keep your appointment, please call us at least 24 hours in advance so that we may offer that appointment to another patient. Patients that miss two consecutive appointments will be charged a $20 no-show fee and the fee must be paid before another appointment can be made. Please keep in mind that three missed appointments may be cause for discharging a patient from the practice.

  • We strive to provide excellent customer service and accommodate your needs in a timely fashion. Unpredictable situations may occur with patients who require extra attention during the course of the day. We appreciate your understanding when there are delays. The same courtesy will be extended to you when you have additional needs.