Online Patient Form

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After completing all the forms, please submit your data on the final tab. Thank you!


Title First * Last * MI Suffix Nickname
Address: *
City: * State: * ZipCode: *
Home Phone: Work Phone:
Other Phone:
Cell Phone: * Preferred Contact Method:
SSN Email
Birthday * Occupation
Sex * Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status * Employer / School Name
Is the patient a minor? Yes No      Guardian Information:
Billing Information Is The Billing Address the Same?
Title First Last MI Suffix

City State ZipCode
Home Phone:
Work Phone:


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:
City: State: Zip:
Phone Number:


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:
City: State: Zip:
Phone Number:

Medical History

Medical History

Please list any major injuries, surgeries, or hospitalizations you've had:
Pregnant Or Nursing?: *
Primary Care Physician: Last Visit: Reason:

Medications Drug Allergies
Vitamins Over the Counter Meds

Eye History

Do you have any of these eye conditions?

Eye Allergies: * Cataracts: *
Eye Infection: * Glaucoma: *
Macular Degeneration: * Lazy Eye: *
Retinal Detachment: * Dry Eye: *
Diabetic Eye Disease: * Other:

Eye injuries or surgeries?: * Eye Medications: *
Vision Correction: * Age of glasses: *
Previous Eye Doctor: Last Eye Exam: *

Family Medical History

Does anyone in your family have these eye conditions?

Crossed/Lazy Eye: * Cataracts: *
Retinal Detach: * Blindness:*
Macular Degen: * Glaucoma: *
Diabetic Retinopathy: * Eye Injury: *
Iritis: * Eye Surgery or Lasik: *
Color Deficiency: * Other:

Does anyone in your family have these medical conditions?

Multiple Sclerosis: * Cancer: * Arthritis: *
Heart Disease: * Diabetes (Type 1/Type2) : * Genital/Kidney/Bladder: *
Gastrointestinal: * High Cholesterol: * Thyroid Disorder: *
High Blood Pressure: * Autoimmune Disease: * Respiratory Disorder: *
Neurological Disease: * Mental Illness: * Other:

Review of Systems

Constitutional: * (Ex. Fever, Weight Loss, Weight Gain, Fatigue)
Skin: * (Ex. Growths, Rashes, Acne)
Neurological: * (Ex. Headaches, MS, Seizures, Autism)
Endocrine: * (Ex. Thyroid Disease, Diabetes)
Ear/Nose/Throat: * (Ex. Allergies, Sinus, Cough, Dry Mouth/Throat)
Respiratory: * (Ex. Asthma, Bronchitis, Emphysema, COPD)
Cardiovascular: * (Ex. High BP, Heart Surgery, Vascular Disease)
Gastrointestinal: * (Ex. Diarrhea, Constipation, Ulcer, Reflux)
Genitourinary: * (Ex. Kidney, Bladder Disease)
Musculoskeletal: * (Ex. Arthritis, Joint Pains, Head or Neck Injury)
Blood/Lymph: * (Ex. Anemia, Bleeding Problems)
Allergic/Immune: * (Ex. Seasonal Allergies, AIDS, Lupus)
Psychiatric: * (Ex. Depression, Anxiety, Insomnia)

Social History

Preferred Language: * Ethnicity: * Race: *

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


Policies, Consent and Submit Data




We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. In the event we make a material change in our privacy practices, we will change this Notice and provide it to you. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.


We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to an optician, ophthalmologist or other healthcare provider providing treatment to you for: a) the provision, coordination, or management of health care and related services by health care providers; (b) consultation between health care providers relating to a patient; (c) the referral of a patient for health care from one health care provider to another; or (d) recall information.

Payment: We may use and disclose your health information to obtain payment for services we provide to you. This may include: (a) billing and collection activities and related data processing; (b) actions by a health plan or insurer to obtain premiums or to determine or fulfill its responsibilities for coverage and provision of benefits under its health plan or insurance agreement, determinations of eligibility or coverage, adjudication or subrogation of health benefit claims; (c) medical necessity and appropriateness of care reviews, utilization review activities; and (d) disclosure to consumer reporting agencies of information relating to collection of premiums or reimbursement.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include things such as quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

Marketing Health Products or Services: We will not use your health information for marketing communications without your prior written authorization. We may provide you with information regarding products or services that we offer related to your health care needs. We will never sell your health information without your prior authorization.

To You, Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so or, if you are not able to agree, if it is necessary in our professional judgment.

Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Required by Law: We may use or disclose your health information when we are required to do so by law, including judicial and administrative proceedings.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders and Treatment Alternatives: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters) or information about treatment alternatives or other health-related benefits and services that may be of interest to you.


Access: You have the right to review or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations, where you have provided an authorization and certain other activities, for the last 6 years, but not for disclosure made prior to April14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request in writing that we communicate with you about your health information by alternative means or to alternative locations. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our a Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.


If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Please check, sign, and date that you have read and agree to our policies and click the SUBMIT button to complete your online forms. Thank you!

Office Policies

Release of Information

I (we) the undersigned patient and/or responsible party hereby authorize this office, its agents/employees to release and disclose all of part of our medical records.

I (we) authorize the release and disclosure of any and all medical records to any other entity including but not limited to referring physicians, hospitals, or other health care providers which may be of assistance in the opinion of this office, in providing for the treatment of the patient.

I (we) authorize the release of records necessary to assist in reimbursement of benefits to which I (we) may be entitled. I (we) authorize this office and/or its employees to release via fax machine medical records which are needed in order to provide the patient with the most appropriate medical care.

I (we) the undersigned patient and/or responsible party hereby authorize this office to release medical, billing, and appointment information to the following family members in lieu of myself:

1. Name: Relationship:
2. Name: Relationship:
3. Name: Relationship:


Post Falls Optometric is happy to bill our patients insurance carriers as a courtesy when they present with a current insurance card, however, we are not contracted with all insurances nor do we know your individual policy, so please contact your carrier before you are seen to verify your benefits for services you may receive. It is ALWAYS the patient's responsibility to know their insurance carriers benefits and policies.

Your medical copay, coinsurance, and deductible will apply to all initial visits and subsequent follow-up visits.
* Medicare does not cover any services unless there is a medical diagnosis. Medicare does not cover the refraction portion of the eye exam or vision hardware unless billed as a post-cataract benefit.

Agreement to Pay for Treatment

The patient and responsible party listed below hereby agree to pay all charges submitted by this office during the course of treatment for the patient. If the patient has insurance coverage with which this office has a contractual agreement, the patients and/or responsible party also agrees to pay for treatment rendered to the patient. In the case of non-payment by contracted carrier, the patient is ultimately responsible for payment and follow-ups with the carrier for services rendered.

I realize that failure to keep this account current may result in my being unable to receive additional services except for emergencies. In the case of default on payment, I understand that my account may be turned to a collection agency along with possible termination of care with this clinic.

I, the undersigned patient, and/or the responsible party have read and received a copy of Post Falls Optometric Policies.

Patient Signature: