Online Patient Form

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Demographics


Title First Last MI Suffix Preferred Name
Address:
City: State:    Zip Code:
Cell Phone: Home Phone:
Work Phone: Other Phone:
SSN Email
Birthday Preferred Contact Method:
Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer / School Name
Primary Doctor Guardian Name: (if patient is a minor under 18)
Referred By: Emergency Contact:

Primary Insurance

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:
SSN:
Employer/School:

Secondary Insurance

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:
SSN:
Employer/School:

Vision Insurance

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:
SSN:
Employer/School:

Medical History

Reason for Visit: Secondary Reasons:

Family History Unknown
  You    Mom    Dad    Sibling    None    Describe:
Diabetes:                  Year Diagnosed: A1c:
Blood Pressure:                 
Thyroid:                 
Heart Disease:                 
Cancer:                 

Pregnant/Nursing: Last Physical Exam:
Major Injuries/Surgeries: Other Medical History:
Name of your Primary Care Doctor and Phone Number:

Review of Systems

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

Eye History

  You    Mom    Dad    Sibling    None    Describe:
Glaucoma:                 
Macular Degen:                 
Retinal Problems:                 
Cataracts:                 
Lazy/Crossed Eye:                 

Last Eye Exam: By Doctor:
Do you have Backup Glasses?: Do you have Sunglasses?: Interested in Contacts?:
Eye Injuries/Surgeries: Other Eye History:
Prescription/Over The Counter Drops:

Vitamins:  Medications: No Medications Medication Allergies: No Known Drug Allergies
 

Social History

Hobbies:   Do You Live Alone?:
Alcohol:  Smoking Status:
Race:        Ethnicity:


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:

Acknowledgment of Notice of Privacy Practices


Decatur Eye Center ~ 303 S. Washburn St. Decatur Texas 76234 ~ (940) 627-2020

I read or was given the opportunity to read, Decatur Eye Center's Notice of Privacy Practice prior to any services offered.

Click the link below to view the Full Notice of Prvacy Practices document.

View Notice of Privacy Practices

The Notice of Privacy Practice could not be read due to the emergent nature of the care and will be acquired when possible


I authorize Decatur Eye Center to release my personal health information to the following individuals:


Our office may use texts and emails to communicate with you. Although HIPAA compliant, they may not be encrypted and complete privacy cannot be guaranteed.

I authorize the use of text and email.
I do not authorize the use of text and email to communicate with me.


I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.

Signature: Date:


If you are signing as a personal representative of the patient, please indicate your relationship. If you are signing for a minor, you attest that you have the legal authority to make medical decisions for the minor and consent to such care. Please indicate any other parent, step-parent, guardian or other individual(s) authorized to make medical decisions for the minor.

Representative Signature:
Relationship to Patient:

Other individuals authorized to make legal decisions for the minor:
Other individuals authorized to make legal decisions for the minor:

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