Mr. Mrs. Ms. Dr. Rev. Fr. Miss
Address:
Apt/Suite #:
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:
Cell Phone:
Preferred Contact Method:
Home Phone Work Phone Cell Phone Other Phone Text Message Email
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
No Doctor Assigned Dr. MCINTYRE, JOHN R. Dr. GARZA, EDWARD Dr. AVILA, CATHY Dr. JURICA, ADAM Dr. LAZARTE, RICHARD Dr. BHAKTA, SAMIR
Misc/Guardian
Billing Information ?Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Address
City
State
ZipCode
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:
City: State: Zip:
Phone Number:
Birthday:
Employer/School:
What is your age?
What is your preferred name or nickname?
Are you male or female?
_ M F
What are you coming in the office for?
CONTACT LENS AND GLASSES GLASSES REFRACTIVE OFFICE VISIT RECHECK CL EVAL
What is your occupation/ job?
What do you like to do in your spare time? (hobbies)
N/A COMPUTER BASEBALL BASKETBALL EXCERCISING FISHING FOOTBALL GOLF HUNTING NONE PIANO READING RUNNING SOCCER TENNIS
When was your last eye exam?
1 YR 2 YR 3 YR 4 YR 5 YR >5 YRS DON'T KNOW
Are you a former patient of our office?
YES NO
If you are a new patient of our office, how did you hear about us?
N/A YAHOO AD FAMILY/FRIEND INSURANCE TV AD INTERNET YELLOW PAGES
Have you worn contact lenses?
Do you want contact lenses?
YES, FT YES, PT NO
If you do wear contact lenses, what solution are you using?
_ I DON'T KNOW OPTIFREE RENU BIOTRUE CLEARCARE GENERIC BRAND
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?
_ NO YES, DRY YES, ITCHY YES, DRY AND ITCHY SOMETIMES DRY SOMETIMES ITCHY SOMETIMES DRY / ITCHY
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
English Spanish Pt declined to answer
Race
American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White Pt declined to Answer
Ethnicity
Hispanic or Latino Non-Hispanic or Latino Pt declined to answer
Smoking Status (if age 13 or older)
Current Everyday Smoker Current Someday Smoker Former Smoker Never Smoked Smoker, Current Status Unknown Unknown if ever smoked Pt declined to answer
Do you have High Blood Pressure?
No Yes Pt declined to answer
Height (in feet)
inches
Weight (in lbs)
Is there anything else you would like to tell us
Insurance Acknowledgment
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.
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:
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 $233.00 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.
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.