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Demographics

General Information
TitleFirstLastMISuffixNickname

 

Address:


City:

State/ZipCode

Home Phone:

Work Phone:

Cell Phone:

SSN

Email

Birthday

Occupation

Sex

Male Female

Employment Status

Employed Full-Time Student Part-Time Student

Marital Status

Employer/School Name

Primary Doctor

Misc/Guardian

 

 

Billing Information ?Is The Billing Address the Same?

Title

First

Last

MI

Suffix

Address

City

State

ZipCode

 

Home Phone:

Work Phone:

Vision

Insurance Information
Insurance Name:

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:

Employer/School:

Primary Medical

Insurance Information
Insurance Name:

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:

Employer/School:

Secondary Medical

Insurance Information
Insurance Name:

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:

Employer/School:

Medical History

What is your age?

 

What is your preferred name or nickname?

 

Are you male or female?

 

What are you coming in the office for?

 

What is your occupation/ job?

 

What do you like to do in your spare time? (hobbies)

 

When was your last eye exam?

 

Are you a former patient of our office?

 

If you are a new patient of our office, how did you hear about us?

 

Have you worn contact lenses?

 

Do you want contact lenses?

 

If you do wear contact lenses, what solution are you using?

 

What vision complaints are you having?

 

What medical complaints are you having with your eyes? (ie floaters, itchy, headaches, red eyes, etc.)

 

Are you having dry or itchy eyes?

 

What medications are you taking for your health?

 

What eye drops / eye medications are you using?

 

What eye problems or diseases do you have? (ie glaucoma, eye injury, eye surgery, etc.)

 

What eye diseases does anyone in the family have? (glaucoma, macular degeneration, etc.)

 

What medical diseases or problems do you have? (ie. diabetes, high blood pressure, cancer, etc.)

 

What medical diseases does anyone in your family have? (ie. diabetes, high blood pressure, cancer, etc.)

 

Could you please tell us something about yourself?  (ie. just graduated, retired, have grandkids, likes to skydive, etc.)

 

The following questions are for insurance purposes.  If you don’t want to respond please write “pt. declined to answer”.  Thanks so much.

 

 

Preferred Language

 

Race

 

Ethnicity

 

Smoking Status (if age 13 or older)

 

Do you have High Blood Pressure?

 

Height (in feet)

 

inches

 

Weight (in lbs)

 

Is there anything else you would like to tell us

 

 

 

 

 

 

 

 

Submit Data

Notice of Privacy Practices

This notice of privacy practices ("notice") describes how we may use for disclose your health information and how you can get access to such information. Please read it carefully.

Your "health information," for purposes of this Notice, is generally any information that identifies you and is created, received, maintained or transmitted by us in the course of providing health care items or services to you (referred to as "health information" in this Notice).

We are required by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and other applicable laws to maintain the privacy of your health information, to provide individuals with this Notice of our legal duties and privacy practices with respect to such information, and to abide by the terms of this Notice. We are also required by law to notify affected individuals following a breach of their unsecured health information.

Uses and Disclosures of Information Without Your Authorization
The most common reasons why we use or disclose your health information are for treatment, payment or health care operations. Examples of how we use or disclose your health information for treatment purposes are: setting up an appointment for you; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and faxing them to be filled; showing you low vision aids; referring you to another doctor or clinic for eye care or low vision aids or services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or vision care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). "Health care operations" mean those administrative and managerial functions that we must carry out in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.

Other Disclosures and Uses we May Make Without Your Authorization or Consent
In some limited situations, the law allows or requires us to use or disclose your health information without your consent or authorization. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:

- When a state or federal law mandates that certain health information be reported for a specific purpose;
- For public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;
- Disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
- Uses and disclosures for health oversight activities. such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
- Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
- Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;
- Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
- Uses or disclosures for health related research;
- Uses and disclosures to prevent a serious threat to health or safety;
- Uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
- Disclosures of de-identified information;
- Disclosures relating to worker's compensation programs;
- Disclosures of a "limited data set" for research, public health, or health care operations;
- Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
- Disclosures to "business associates" and their subcontractors who perform health care operations for us and who commit to respect the privacy of your health information in accordance with HIPAA;
- [specify other uses and disclosures affected by state law].

Unless you object, we will also share relevant information about your care with any of your personal representatives who are helping you with your eye care. Upon your death, we may disclose to your family members or to other persons who were involved in your care or payment for heath care prior to your death (such as your personal representative) health information relevant to their involvement in your care unless doing so is inconsistent with your preferences as expressed to us prior to your death.

Specific Uses and Disclosures of Information Requiring Your Authorization
The following are some specific uses and disclosures we may not make of your health information without your authorization:
Marketing activities. We must obtain your authorization prior to using or disclosing any of your health information for marketing purposes unless such marketing communications take the form of face-to-face communications we may make with individuals or promotional gifts of nominal value that we may provide. If such marketing involves financial payment to us from a third party your authori zation must also include consent to such payment.
Sale of health information. We do not currently sell or plan to sell your health information and we must seek your authorization prior to doing so.
Psychotherapy notes. Although we do not create or maintain psychotherapy notes on our patients, we are required to notify you that we generally must obtain your authorization prior to using or disclosing any such notes.

Your Rights to Provide an Authorization for Other Uses and Disclosures
- Other uses and disclosures of your health information that are not described in this Notice will be made only with your written authorization.
- You may give us written authorization permitting us to use your health information or to disclose it to anyone for any purpose.
- We will obtain your written authorization for uses and disclosures of your health information that are not identified in this Notice or are not otherwise permitted by applicable law.
- We must agree to your request to restrict disclosure or your health information to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and such information pertains solely to a health care item or service for which you have paid in full (or for which another person other than the health plan has paid in full on your behalf).

Any authorization you provide to us regarding the use and disclosure of your health information may be revoked by you in writing at any time. After you revoke your authorization, we will no longer use or disclose your health information for the reasons described in the authorization. However, we are generally unable to retract any disclosures that we may have already made with your authorization. We may also be required to disclose health information as necessary for purposes of payment for services received by you prior to the date you revoked your authorization.

Your Individual Rights
You have many rights concerning the confidentiality of your health information. You have the right:

To request restrictions on the health information we may use and disclose for treatment, payment and health care operations. We are not required to agree to these requests. To request restrictions. please send a written request to us.
To receive confidential communications of health information about you in any manner other than described in our authorization request form. You must make such requests in writing. However, we reserve the right to determine if we will be able to continue your treatment under such restrictive authorizations.
To inspect or copy your health information. You must make such requests in writing to the address below. If you request a copy of your health information we may charge you a fee for the cost of copying, mailing or other supplies. In certain circumstances we may deny your request to inspect or copy your health information, subject to applicable law.
To amend health information. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, you must write to us. You must also give us a reason to support your request. We may deny your request to amend your health infonnation if it is not in writing or does not provide a reason to support your request. We may also deny your request if the health information: was not created by us, unless the person that created the information is no longer available to make the amendment; is not part of the health information kept by or for us; is not part of the information you would be permitted to inspect or copy; or is accurate and complete.
To receive an accounting of disclosures of your health information. You must make such requests in writing. Not all health information is subject to this request. Your request must state a time period for the information you would like to receive, no longer than 6 years prior to the date of your request and may not include dates before April 14. 2003. Your request must state how you would like to receive the report (paper, electronically).
To designate another party to receive your health information. If your request for access of your health information directs us to transmit a copy of the health information directly to another person the request must be made by you in writing to the address below and must clearly identify the designated recipient and where to send the copy of the health information.

Complaints
If you think that we have not properly respected the privacy of your health information, you are free to complain to us or to the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. lf you want to complain to us, send a written complaint to the office contact person at the address, fax or email shown above. If you prefer, you can discuss your complaint in person or by phone.

Changes to This Notice:
We reserve the right to change our privacy practices and to apply the revised practices to health information about you that we already have. Any revision to our privacy practices will be described in a revised Notice that will be posted prominently in our facility. Copies of this Notice are also available upon request at our reception area.

You can also view and print a copy of this notice here.

Medicare

Coverage Overview
Medicare is your primary health insurance and for your convenience, our office is a participating provider with Medicare. This means that our office will bill Medicare for your office visit. Medicare then reviews all your submitted claims and if approved will reimburse our office. You may also be responsible for a deductible and certain non-covered fees which Medicare or your supplement may not cover. If not covered by Medicare, we will bill you directly for your portion of the fees.

Deductible
Medicare has a yearly deductible of $166.00 that takes effect each January. If our office is the first to submit a claim for you, Medicare will notify us that you have yet to meet your deductible for the year. Medicare will not pay for your visit until the deductible has been met.

Exceptions, Non-Covered Service and Material Fees
Medicare does not pay for refractive services. This is the part of your eye exam that determines your prescription. Medicare will not pay for any services if the doctor only makes a refractive diagnosis during your exam.

Authorization Statement/Signature
I have read and understand the information above and agree to pay for any services that are not covered by Medicare. By signing below I agree to allow this practice to communicate with me via text, email, portal, or telephone.

Print Name: Signature: Date:

Insurance Acknowledgement

I acknowledge that the benefits quoted are not a guarantee of payment until your insurance has processed the claim. If I am not eligible for these benefits I am responsible for the balance. If Drs. McIntyre, Garza, Avila, and Jurica are accepting my medical benefits I will be required to pay for the refraction at the time of the services since it is not a covered charge. By signing this form, I acknowledge that I have reviewed the information and the practice's policy notice and agree to the practice's use and disclosure of my protected health information and I agree to allow this practice to communicate with me via text, email, postal, or telephone.

Signature: Date:

Are you sure all of the information you gave us is correct? If so, please click Submit Data below.

Please bring your drivers license, all your insurance cards, any glasses you wear, and any contact lens related items you use (solutions, drops, cleaners, packages or boxes with contact lens prescription) to your appointment. Kindly give 24 hrs notice if you need to reschedule your appointment.