Online Patient Form
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Demographics
Title
First
Last
MI
Suffix
Preferred Name
Mr.
Mrs.
Ms.
Dr.
Rev.
Miss
Address:
City:
State:
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
Zip Code:
Home Phone:
Work Phone:
Other Phone:
Alerts:
Cell Phone:
Preferred Contact Method:
Home Phone
Work Phone
Cell Phone
Other Phone
SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Employer / School Name
Primary Doctor
Edward Fries, OD
Guardian Name:
(if patient is a minor under 18)
Referred By:
Primary Insurance
Insurance Name:
None
AARP
Academy Life Ins Co
Aetna
Aetna - Continental Life Insurance
AFLAC
American Capitol Insurance Co
American Continental
American Exchange
American Life & Accident
American Life Assurance
American Pioneer Life
American Retirement
Ameritas
Bankers Commercial Life
Bankers Life and Casuality
BCBS of Alabama
BCBS of California
BCBS of Illinois
BCBS of Michigan
BCBS of TX
BCBS of TX (SEC)
Benefit Planners
Block Vision
Bravo Health
Care Improvement Plus
Central Reserve Life
Champva
Christian Fidelity Life
Cigna
Cigna Secondary
Colonial Penn
Combined Ins Co
Conseco
Continental General
Coventry Health Care
Dallas General Life Ins
Davis Vision
Equitable Life
EyeMed
Family Life
Farm Bureau Insurance
First National Life
Fiserve Health
Forethought
GEHA
Gerber Life Insurance
Golden Rule Ins
Group & Pension Administrators
Harris Methodist Health
Hartford Life & Accident
HealthPartners
Heartland
Humana
Imperial Group
Insurance
International Benefits
Life Investors
Loyal American Life
Mail Handlers Benefit Plan
Medicaid
Medicaid/Amerigroup
Medicaid/Healthsprings
Medicare
Mediplus
Meritain Health
Mutual of Omaha
NALC
National Elevator Industry
National Foundation Life
Newera
North American Insurance Company
Old Surety Life
Opti-Care
Oxford Health
Oxford Life
Paccar The Principal Mutual
Pacificare
Pacificare Senior Plan
Palmetto/DMERC
PCIP
Pennsylvania Life Ins
PHCS
Philadelphia American
Physicians Mutual Ins
Pioneer Life Insurance Co
Principal Life Insurance
Principal Mutual Life
Provident American
Providential Life Ins
Pyramid
Pyramid Life
Railroad MC
Reserve National
Royal Neighbors of America
Secondary
Sentinel Security Life
Southwest Sevice Life
Standard Life & Accident
State Farm Ins
State Mutual Insurance
Stateman National Life Ins
Sterling Insurance
Superior Vision
Texas True Choice
TML Intergovernment Employee Benefits Pool
Transamerica
Tricare/WPS
TriWest
TROA Group Health Ins
UHC
UMR
Unicare
Unicare
United American Ins
United Commercial Traveler
United Teachers Assoc
Universal Fidelity life
USAA
USMS Amarillo Office
VSP
Wise County Indigent Care
Woodmen of the World
World Insurance
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
Insurance Name:
None
AARP
Academy Life Ins Co
Aetna
Aetna - Continental Life Insurance
AFLAC
American Capitol Insurance Co
American Continental
American Exchange
American Life & Accident
American Life Assurance
American Pioneer Life
American Retirement
Ameritas
Bankers Commercial Life
Bankers Life and Casuality
BCBS of Alabama
BCBS of California
BCBS of Illinois
BCBS of Michigan
BCBS of TX
BCBS of TX (SEC)
Benefit Planners
Block Vision
Bravo Health
Care Improvement Plus
Central Reserve Life
Champva
Christian Fidelity Life
Cigna
Cigna Secondary
Colonial Penn
Combined Ins Co
Conseco
Continental General
Coventry Health Care
Dallas General Life Ins
Davis Vision
Equitable Life
EyeMed
Family Life
Farm Bureau Insurance
First National Life
Fiserve Health
Forethought
GEHA
Gerber Life Insurance
Golden Rule Ins
Group & Pension Administrators
Harris Methodist Health
Hartford Life & Accident
HealthPartners
Heartland
Humana
Imperial Group
Insurance
International Benefits
Life Investors
Loyal American Life
Mail Handlers Benefit Plan
Medicaid
Medicaid/Amerigroup
Medicaid/Healthsprings
Medicare
Mediplus
Meritain Health
Mutual of Omaha
NALC
National Elevator Industry
National Foundation Life
Newera
North American Insurance Company
Old Surety Life
Opti-Care
Oxford Health
Oxford Life
Paccar The Principal Mutual
Pacificare
Pacificare Senior Plan
Palmetto/DMERC
PCIP
Pennsylvania Life Ins
PHCS
Philadelphia American
Physicians Mutual Ins
Pioneer Life Insurance Co
Principal Life Insurance
Principal Mutual Life
Provident American
Providential Life Ins
Pyramid
Pyramid Life
Railroad MC
Reserve National
Royal Neighbors of America
Secondary
Sentinel Security Life
Southwest Sevice Life
Standard Life & Accident
State Farm Ins
State Mutual Insurance
Stateman National Life Ins
Sterling Insurance
Superior Vision
Texas True Choice
TML Intergovernment Employee Benefits Pool
Transamerica
Tricare/WPS
TriWest
TROA Group Health Ins
UHC
UMR
Unicare
Unicare
United American Ins
United Commercial Traveler
United Teachers Assoc
Universal Fidelity life
USAA
USMS Amarillo Office
VSP
Wise County Indigent Care
Woodmen of the World
World Insurance
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:
Vision Insurance
Insurance Name:
None
AARP
Academy Life Ins Co
Aetna
Aetna - Continental Life Insurance
AFLAC
American Capitol Insurance Co
American Continental
American Exchange
American Life & Accident
American Life Assurance
American Pioneer Life
American Retirement
Ameritas
Bankers Commercial Life
Bankers Life and Casuality
BCBS of Alabama
BCBS of California
BCBS of Illinois
BCBS of Michigan
BCBS of TX
BCBS of TX (SEC)
Benefit Planners
Block Vision
Bravo Health
Care Improvement Plus
Central Reserve Life
Champva
Christian Fidelity Life
Cigna
Cigna Secondary
Colonial Penn
Combined Ins Co
Conseco
Continental General
Coventry Health Care
Dallas General Life Ins
Davis Vision
Equitable Life
EyeMed
Family Life
Farm Bureau Insurance
First National Life
Fiserve Health
Forethought
GEHA
Gerber Life Insurance
Golden Rule Ins
Group & Pension Administrators
Harris Methodist Health
Hartford Life & Accident
HealthPartners
Heartland
Humana
Imperial Group
Insurance
International Benefits
Life Investors
Loyal American Life
Mail Handlers Benefit Plan
Medicaid
Medicaid/Amerigroup
Medicaid/Healthsprings
Medicare
Mediplus
Meritain Health
Mutual of Omaha
NALC
National Elevator Industry
National Foundation Life
Newera
North American Insurance Company
Old Surety Life
Opti-Care
Oxford Health
Oxford Life
Paccar The Principal Mutual
Pacificare
Pacificare Senior Plan
Palmetto/DMERC
PCIP
Pennsylvania Life Ins
PHCS
Philadelphia American
Physicians Mutual Ins
Pioneer Life Insurance Co
Principal Life Insurance
Principal Mutual Life
Provident American
Providential Life Ins
Pyramid
Pyramid Life
Railroad MC
Reserve National
Royal Neighbors of America
Secondary
Sentinel Security Life
Southwest Sevice Life
Standard Life & Accident
State Farm Ins
State Mutual Insurance
Stateman National Life Ins
Sterling Insurance
Superior Vision
Texas True Choice
TML Intergovernment Employee Benefits Pool
Transamerica
Tricare/WPS
TriWest
TROA Group Health Ins
UHC
UMR
Unicare
Unicare
United American Ins
United Commercial Traveler
United Teachers Assoc
Universal Fidelity life
USAA
USMS Amarillo Office
VSP
Wise County Indigent Care
Woodmen of the World
World Insurance
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
Reason for Visit:
Secondary Reasons:
Family History Unknown
You
Mom
Dad
Sibling
None
Describe:
Diabetes:
None
Type 1 Diabetes
Type 2 Diabetes
Gestational Diabetes
Hypoglycemic
Borderline, Controlled by Diet/Exercise
Other
Year Diagnosed:
A1c:
Blood Pressure:
None
Medicine Controls
Controlled by Diet/Exercise
Other
Thyroid:
None
Hyperthyroid
Grave's Disease
Hypothyroid
Hashimoto's Disease
Medication Controls
Other
Heart Disease:
None
A-Fib
Abdominal Aneurism
Aortic Aneurism
Heart Attack
Lymphedema
Murmur
MVP
Peripheral Arterial Disease
Raynaud's Disease
Stroke
Heart Disease
Aortic Aneurism
Other
Cancer:
None
Active
Cured
Remission
Basal Cell
Bladder
Bone
Brain
Breast
Cervical
Colon
Lsophageal
Leukemia
Liver
Lung
Lymphoma
Melanoma
Myeloma
Ovarian
Pancreas
Prostate
Squamous Cell
Stomach
Testicular
Thyroid
Other
Pregnant/Nursing:
No
Unsure
Pregnant
Nursing
Other
Last Physical Exam:
Major Injuries/Surgeries:
Other Medical History:
Primary Care Physician:
Review of Systems
General:
None
Weight Loss/Gain
Fever
Fatigue
Trauma
Cancer
Other
Ear/Nose/Throat:
None
Allergies
Hearing Loss
Ear ache
Nasal Congestion
Chronic Cough
Nasal Drip
Dry Mouth
Other
Respiratory:
None
Asthma
Emphysema
Bronchitis
Shortness of Breath
Tuberculosis
Other
Cardiovascular:
None
Heart/ Vascular Disease
Stroke
Blood Pressure
Cholesterol
Other
Endocrine:
None
Diabetes
Sweating
Change in Appetite
Gout
Thyroid Disorder
Other
Musculoskeletal:
None
Fibromyalgia
Arthritis
Swelling
Muscular Dystrophy
Other
Skin:
None
Eczema
Rosacea
Psoriasis
Warts
Rashes
Other
Genitourinary:
None
Urination Issues
Kidney Issues
HIV
Hepatitis
Chlamydia
Gonorrhea
Other
Psychiatric:
None
Anxiety
Bipolar
Depression
Panic Disorder
Schizophrenia
Memory Issues
Sleep Problems
Other
Neurological:
None
Multiple Sclerosis
Epilepsy
Vertigo
Balance Issues
Dementia
Other
Allergic / Immunologic:
None
General Allergy
Lupus
Rheumatoid Arthritis
Other
Gastrointestinal:
None
Crohn's Disease
Colitis
Hernia
Ulcers
Digestive Issues
Other
Lymph/Blood:
None
Anemia
Bleeding Issues
Blood Transfusion Issues
Other
Eye History
You
Mom
Dad
Sibling
None
Describe:
Glaucoma:
None
Angle Recession
COAG
ICE
POAG
NAG
Narrow Angles
Neovascular
Ocular Hypertension
Pigmentary
Pseudoexfoliative
Secondary
Suspect
Traumatic
POAG
Other
Macular Degen:
None
Dominant Familial Drusen
Drusen
Dry AMD
Geographic Atrophy
Wet AMD
Other
Retinal Problems:
None
CME
CSR
DME
ERM
Histoplamosis
Hypertensive Retinopathy
Macular Cyst
Macular Hole
NPDR
PDR
Retinal Detachment
Retinal Hole
Retinal Tear
Retinitis Pigmentosa
Stargardt's
Toxoplasmosis
Other
Cataracts:
None
Suspect
Congenital
Cortical
NS
PSC
Traumatic
Other
Lazy/Crossed Eye:
None
Accom ET
CN3 Palsy
CN4 Palsy (SO)
CN6 Palsy (LR)
Double Hyper
Duane's Retraction Syndrome
ET
Hypertropia
Intermittent XT
Muscle Surgery
No Patching
Patching Therapy
Refractive Amblyopia
Strabismic Amblyopia
VT
XT
Other
Last Eye Exam:
By Doctor:
Do you have Backup Glasses?:
Yes
No
Do you have Sunglasses?:
Yes
No
Interested in Contacts?:
Yes
No
Eye Injuries/Surgeries:
Other Eye History:
Prescription/Over The Counter Drops:
Vitamins:
Medications:
No Medications
Medication Allergies:
No Known Drug Allergies
Social History
Hobbies:
Arts and Crafts
Astronomy
Baseball
Basketball
Boating
Computer games
Cooking
Dancing
Diving
Fishing
Football
Gardening
Golf
Hiking
Horseback Riding
Hunting
Kid's activities
Models
Needlepoint
None
Paddling
Painting
Photography
Piano
Reading
Roller Blading
Running
Sewing
Skiing
Soccer
Softball
Swimming
Tennis
Travel
Video Games
Woodworking
Other
Do You Live Alone?:
assisted living
No
nursing home
Yes
Other
Alcohol:
None
occasional
social
1-2 drinks/day
several drinks/day
Other
Smoking Status:
Never smoker (<100 cigs equiv)
Former smoker (no longer smokes)
Current some day smoker (not daily)
Light smoker (<10 cigs/day)
Heavy smoker (>10 cigs/day)
Smoker (current status unknown)
Current every day smoker
Unknown if ever smoked
Other
Race:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other Race
Patient Declined to Specify
Other
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown
Patient Declined to Specify
Other
To allow us to file on your insurance and accept assignment please sign the following release:
I request that insurance benefits be paid directly to Dr. Fries for services rendered. I authorize the release of information to my insurance carriers for determination of benefits.
Signature:
Date:
WAIVER OF LIABILITY DELUXE FRAMES
(Only Eligible Once A Lifetime After Cataract Surgery)
Standard frames are available fo purchase from Decatur Eye Center at no extra charge, however if you choose to go over and beyond what Medicare covers there will be an extra charge that you the patient will be responsible for.
Signature:
Date:
MEDICAID EYEGLASS CERTIFICATION FORM
I,
, certify that:
A. I was offered a selection of serviceable glasses at no cost to me, but i desired a type or style of eyewear beyond Medicaid program.
I will be responsible for any balance for eyewear beyond Medicaid program benefits.
B. The glasses that are being replaced were unintenionally lost or destroyed.
Medicaid Client Signature:
Witness Signature:
Date:
Date:
Client Medicaid Number:
Information Release
Name of your Primary Care Doctor and Phone Number:
I allow the following person(s) to call and inquire about my office visits/medical records/appointments/glasses or contact lens information:
If their name is not on this form, we WILL NOT be able to release items/information to them.
Please recognize
Relationship:
Phone Number:
Is this an emergency contact?
Yes
Please recognize
Relationship:
Phone Number:
Is this an emergency contact?
Yes
Please recognize
Relationship:
Phone Number:
Is this an emergency contact?
Yes
I understand that I may revoke this personal representative recognition, in writing, at any time.
Signature:
Date:
If not signed by the patient, please indicate relationship to the patient:
Parent or guardian of minor patient
Guardian or conservator of an incompetent patient
Beneficiary of personal representative of deceased patient
Other:
Print name if not signed by the patient:
Notice Of Privacy Practices
Your Information. Your Rights. Our Responsibilities.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get an electronic or paper copy of your medical record You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say "no" to your request, but weâÃÂÃÂll tell you why in writing within 60 days.
Request confidential communications
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say "yes" to all reasonable requests.
Ask us to limit what we use or share
You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to share that information.
Get a list of those with whom we've shared information
You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
You can complain if you feel we have violated your rights by contacting us using the information on this form. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting:
www.hhs.gov/ocr/privacy/hipaa/complaints/
We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: Share information with your family, close friends, or others involved in your care Share information in a disaster relief situation Include your information in a hospital directory If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases, we never share your information unless you give us written permission: Marketing purposes Sale of your information Most sharing of psychotherapy notes
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways:
Treat you
We can use your health information and share it with other professionals treating you. Example:
A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example:
We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities. Example:
We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
Help with public health and safety issues
We can share health information about you for certain situations such as:
Preventing disease
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyoneâÃÂÃÂs health or safety
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that weâÃÂÃÂre complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Address workers' compensation, law enforcement, and other government requests
We can use or share health information about you:
For workers' compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities
We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Patient Signature:
Date:
Submit Data