Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Preferred Name
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address:
City:		State/ZipCode	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 TX UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
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	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer / School Name
Misc/Guardian		Release of Information / Emergency Contact:

Is the Billing Address Different?

Billing Information

Address Same As Above

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address

City	State	ZipCode
	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 TX UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Medical History

Race	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander Other Race Patient Declined to Specify White Other
Ethnicity:	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other
Preferred Language:	English Spanish French Other Patient Declined to Specify

Height:	ft. in.
Weight:	lbs.

PATIENT MEDICAL HISTORY

Please note any history of the following conditions:

Good health Arthritis Asthma Diabetes HBP Headaches Heart Condition HX Of Drug/Alcohol Abuse Inflammatory Bowel Disease Smoking Seizure Disorder Thyroid Disease Nursing Diagnosed As HIV+ Other Hypertension Hypercholesterolemia Migraines Acid Reflux Sinusitis Muscle/Joint Pain Allergies

Diabetes HBP Heart disease Cancer Arthritis Lupus Kidney Thyroid Back Problems

Arthritis Diabetes HBP Heart Disease Cancer Lupus Kidney Disease Thyroid Disease Back Problems

Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Back Problems

Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Disease Back Problems

Other:

Injuries, Surgeries, Hospitalizations:

Pregnant Or Nursing:	No Yes Unsure
Last Eye Exam:	Never 1 week 1 month 3 months 6 months 1 year 2 years 3 years or longer
Primary Care Physician:

How did you hear about our office?:

Please list all medications you currently take:

Over the Counter:
Vitamins:	None A B C Calcium D E Eye specific vitamin Iron Lutein Multi-Vitamin Unspecified OTC Zeaxanthin Zinc

FAMILY MEDICAL HISTORY

Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions: 

Disease/Condition	Yes	No	Relationship to You
Blindness
Crossed Eyes
Cataract
Glaucoma
Macular Degeneration
Cancer
Diabetes
Heart Disease
High Blood Pressure
Stroke
Thyroid Disease

REVIEW OF SYSTEMS

Do you currently, or have you ever had any problems in the following areas:

Eyes (Ocular symptoms)	Yes	No
Eye Pain or Soreness
Fatigue/Tired Eyes
Foreign Body Sensation
Dryness/ Gritty Feeling
Redness
Burning
Itching
Excess Watering
Mucous Discharge
Chronic Infection of Eye
Eyes (Visual Symptoms)
Squinting
Glare/ Light Sensitivity
Halos
Double Vision
Loss of Vision
Blurred Vision
Flashes
Floaters
Constitutional
Fever
Weight Loss/Gain
Integumentary (Skin)
Rosacea
Metal Allergies
Ears, Nose, Mouth, Throat
Allergies/Hay Fever
Sinus Infections
Hearing Loss
Respiratory
Asthma
Chronic Bronchitis
Emphysema
Vascular/Cardiovascular
Heart Problems/Disease
Congestive Heart Failure
High Blood Pressure
High Cholesterol
Stroke
Gastrointestinal
Acid Reflux
Intestinal Problems
Liver Problems
Endocrine
Thyroid/Other Glands
Diabetes
Genitourinary
Genitals/Kidney/Bladder
Lymphatic/Hematologic
Anemia
Bleeding
Bones/Joints/Muscles
Rheumatoid Arthritis
Muscle Joint/Pain
Neurological
Headaches
Migraines
Seizures
Alzheimer's
Parkinson's
Psychiatric
Immune System

EYE HISTORY

Eye Injuries	Yes	No	(Foreign Objects, Black eye, etc.)
Eye Disease	Yes	No	(Cataract, Glaucoma, Macular Degeneration, Pterygium, etc.)
Eye Surgery	Yes	No	(Cataract, Vision Correction, etc.)

If yes to any of the above, please explain what and when:
 

Have you ever worn soft contacts?	Yes	No
Have you ever worn hard contacts?	Yes	No

Do you use eye drops on a regular basis? If so, what and how often?

SOCIAL HISTORY

Occupation:
Hobbies:

Smoking Status:	Never Smoker Current every day smoker Current some day smoker Former smoker Smoker, currernt status unknown Unknown if ever smoked	Type:	None Cigarettes Chewing Tobacco Cigar Pipe	How Long:
Alcohol:	No Yes Occasionally Socially	Type:	None Beer/Wine Hard Liquor	How Long:
Illegal Drugs:	No Yes	Type:		How Long:

STD's:

Submit Data

Notice of Privacy Practices (HIPAA form)

Whitney Family Eyecare
PO Box 2067, Whitney, TX 76692
254-694-3435 whitneyfamilyeyecare.com
Lon Eubank, Privacy Official

HIPAA

Notice Of Privacy Practices

IN COMPLIANCE WITH THE FEDERAL REGULATIONS OF HIPAA'S PRIVACY RULE, THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO IT.

We respect our legal obligation to keep health information that might identify you private. We are obligated by law to provide you with notice of our privacy practices and abide by the policies in it. This notice describes how we protect your health information and what rights you have regarding it.

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS:

The most common reasons we would use or disclose your health information is for treatment, payment, or business operations. We routinely use and disclose your medical information within the office on a daily basis. We do not need specific permission to use or disclose your medical information in the following matters, although you have the right to request that we do not.

Examples of how we might use or disclose health information for treatment purposes might include:

Setting up or changing appointments including leaving messages with those at your home or office who may answer the phone or leaving messages on answering machines, voice mails, text or email; calling your name out in a reception room environment; prescribing glasses, discussion of lens options while in the optical or during dispensing, prescribing contact lenses, or medications as well as relaying this information to suppliers by phone, fax or other electronic means including initial prescriptions and requests from suppliers for refills; notifying you that your ophthalmic goods are ready, including leaving messages with those at your home or office who may answer the phone, or leaving messages on answering machines, voice mails, text or emails; referring you to another doctor for care not provided by this office; obtaining copies of health information from doctors you have seen before us; discussing your care with you directly or with family or friends you have inferred or agreed may listen to information about your health; sending you postcards or letters or leaving messages with those at your home who may answer the phone or on answering machines, voice mails, text or emails reminding you it is time for continued care; at your request, we can provide you with a copy of your medical records via email transmission or through our secured patient portal.

Examples of how we might use or disclose health information for payment purposes might include:

Asking you about your vision or medical insurance plans or other sources of payment; preparing and sending bills to your insurance provider or to you; providing any information required by third party payors in order to ensure payment for services rendered to you; sending notices of payment due on your account to the person designated as responsible party or head of household on your account with fee explanations that could include procedures performed and for what diagnosis: collecting unpaid balances either ourselves or through a collection agency, attorney, or district attorney's office. At the patient's request we may not disclose to a health plan or health care operation information related to care that you have paid for out of pocket. This only applies to those encounters related to the care you want restricted and only to the extent a disclosure is not otherwise required by law.

Examples of how we might use or disclose health information for business operations might include:

Financial or billing audits; internal quality assurance programs; participation in managed care plans; defense of legal matters; business planning; certain research functions; informing you of products or services offered by our office; compliance with local, state, or federal government agencies request for information; oversight activities such as licensing of our doctors; Medicare or Medicaid audits; providing information regarding your vision status to the Department of Public Safety, a school nurse, or agency qualifying for disability status.

USES AND DISCLOSURES FOR OTHER REASONS NOT NEEDING PERMISSION

In some other limited situations, the law allows us to use or disclose your medical information without your specific permission. Most of these situations will never apply to you but they could.

• When a state or federal law mandates that certain health information be reported for a specific purpose


• For public health reasons, such as reporting of a contagious disease, investigations or surveillance, and notices to and from the federal Food and Drug Administration regarding drugs or medical devices


• Disclosures to government or law authorities about victims of suspected abuse, neglect, domestic violence, or when someone is or suspected to be a victim of a crime


• Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative hearings


• Disclosures to a medical examiner to identify a deceased person or determine cause of death or to funeral directors to aid in burial


• Disclosures to organizations that handle organ or tissue donations


• Uses or disclosures for health related research


• Uses or disclosures to prevent a serious threat to health or safety of an individual or individuals


• Uses or disclosures to aid military purposes or lawful national intelligence activities


• Disclosures of de-identified information


• Disclosures related to a workman's compensation claim


• 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 and disclosures


• Disclosure of information needed in completing form from a school related vision screening, information to the Department of Public Safety, information related to certification for occupational or recreational licenses such as pilots license.


• Disclosures to business associates who perform health care operations for Whitney Family Eyecare and who commit to respect the privacy of your information. We also require any business associate to require any sub-contractor to comply with our privacy policies.


• Unless you object, disclosure of relevant information to family members or friends who are helping you with your care or by their allowed presence cause us to assume you approve their exposure to relevant information about your health

USES OR DISCLOSURES TO PATIENT REPRESENTATIVES:

It is the policy of Whitney Family Eyecare for our staff to take phone calls from individuals on a patients behalf requesting information about making or changing an appointment; the status of eyeglasses, contact lenses, or other optical goods ordered by or for the patient. Whitney Family Eyecare staff will also assist individuals on a patient's behalf in the delivery of eyeglasses, contact lenses, or other optical goods. During a telephone or in person contact, every effort will be made to limit the encounter to only the specifics needed to complete the transaction required. No information about the patient's vision or health status may be disclosed without proper patient consent. Whitney Family Eyecare staff and doctors will also infer that if you allow another person in an examination room, treatment room, dispensary, or any business area within the office with you while testing is performed or discussions held about your vision or health care or your account that you consent to the presence of that individual.

OTHER USES AND DISCLOSURES:

We will not make any other uses or disclosures of your health information or uses and disclosures involving marketing unless you sign a written Authorization for Release of Identifying Health Information. The content of this authorization is determined by applicable state and federal law. The request for signing an authorization may be initiated by Whitney Family Eyecare or by you as the patient. We will comply with your request if it is applicable to the federal policies regarding authorizations. If we ask you to sign an authorization, you may decline to do so. If you do not sign the authorization, we may not use or disclose the information we intended to use. If you do elect to sign the authorization, you may revoke it at any time. Revocation requests must be made in writing to the Privacy Officer named at the beginning of this Notice.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION:

The law gives you many rights regarding your personal health information.

You may ask us to restrict our uses and disclosures for purposes of treatment (except in emergency care), payment, or business operations. This request must be made in writing to Privacy Officer named at the beginning of this Notice. We do not have to agree to your request, but if we agree, must honor the restrictions you ask for.

You may ask us to communicate with you in a confidential manner. Examples might be only contacting you by telephone at your home or using some special email address. We may accommodate these requests if they are reasonable and if you agree to pay any additional cost, if any, incurred in accommodating your request. Requests for special communication requests must be made to the Privacy Officer named at the beginning of this Notice.

You may ask to review or get copies of your health information. For the most part we are happy to provide you with the opportunity to either review or obtain a copy of your medical information but rare situations may restrict release of the information. In such cases we will provide you such denial in writing. Another licensed health care practitioner chosen by Whitney Family Eyecare may review your request and your denial. In such cases we will abide by the outcome of that review. All requests for review or copy of medical information must be made in writing to the Privacy Officer named at the beginning of this Notice. While we usually respond to these requests in just a day or so, by law we have fifteen (15) days to respond to your request. We may request an additional thirty (30) day extension in certain situations.

Health care information you request copies of may be delivered to you in electronic format. The e-formats Whitney Family Eyecare has approved include secure email, an authorized Electronic Health Information system and media supplied by Whitney Family Eyecare.

You may ask us to amend or change your health care information if you think it is incorrect or incomplete. If we agree, we will make the amendment to your medical record within thirty (30) days of your written request for change sent to the Privacy Officer named at the beginning of this Notice. We will then send the corrected information to you or any other individual you feel needs a copy of the corrected information. If we do not agree, you will be notified in writing of our decision. You may then write a statement of your position and we will include it in your medical record along with any rebuttal statement we may wish to include.

You may request a list of any non-routine disclosures of your health information that we might have made within the past six (6) years (or a shorter period if you wish). Routine disclosures would include those used your treatment, payment, and business operations of Whitney Family Eyecare. These routine disclosures will not be included in your list of disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you must pay for them in advance at a fee of $20.00 per list. We will usually respond to your written request (made to the Privacy Officer named at the beginning of this Notice) within thirty (30) days but we are allowed one thirty (30) day extension if we need the time to complete your request.

You may obtain additional copies of this Notice of Privacy Practices from our business office or online at our website address shown at the beginning of this Notice.

BREACH NOTIFICATION POLICY:

In the event of a reportable breach of patient information, Whitney Family Eyecare agrees to abide by the breach notification requirements as established by the HIPAA Breach Notification Rule. If a breach occurs, Whitney Family Eyecare will take all necessary steps to remain in compliance with this rule including as applicable notification of individuals, Business Associates, the Secretary of Health and Human Services and prominent media outlets.

WHISLEBLOWER PROTECTION RULE:

Whitney Family Eyecare will take no action against any individual who provides information to the Office of Civil Rights, Office of the Inspector General or individual state Attorney General's Office regarding concerns related to the privacy and security procedures or actions at Whitney Family Eyecare.

CHANGING OUR NOTICE OF PRIVACY PRACTICES:

By law, we must abide by the terms of this Notice of Privacy Practices until we choose to substantially change the Notice. We reserve the right to change this Notice at any time. If we change this Notice, the new privacy practices will apply to your existing health information as well as any additional information generated in the future. If we change this Notice, we will post a new Notice in our office and on our website.

COMPLAINTS:

If you think that anyone at Whitney Family Eyecare has not respected the privacy of your health information, you are free to complain to the Privacy Officer named at the beginning of this Notice. We are more than happy to try to resolve any concern you may have in writing. You may also file a complaint with the U.S. Department of Health and Human Services, Office of Civil Rights or the state Attorney General's Office. We will not retaliate against you if you make such a complaint.

CHANGING OUR NOTICE OF PRIVACY PRACTICES:

If you have any questions or concerns we encourage you to contact the Privacy Officer at the number on this notice.

Please make a selection below and hit the SUBMIT button to complete your online forms. Thank you!

Do you agree to have your pupils dilated? yes no


Contact Lens Prescription

Signed Acknowledgment Form
• I acknowledge that my contact lens prescription will be uploaded to my patient portal after Dr. Eubank has finalized it.
• I acknowledge that I have been given access to my portal to receive my prescription.
• I understand my contact lens prescription expires one year after my initial exam date of service.

Patient Signature: Date:

Pre Appointment Check List

We want your appointment to be everything you expect from your Whitney Family Eyecare team. To do this we need the most current and accurate information possible so that we can take care of all your needs properly. Please make sure the following items are brought with you to help the process go more smoothly. Thanks so very much.

Pre appointment:

• Complete your online forms via your patient portal. You should have instructions via email
• If your insurance requires a referral (HMO PLAN) Please contact your pcp (we are here to help if you are unsure)
• Check your messages for information regarding your fees or any appointment information that may be shared.
• Confirm your appointment with us. If you need to be rescheduled we require a 24 hour notice.


List of things you will need at your appointment:

• Insurance cards/photo ID
• List of all current medications/Drug allergies
• PCP/Specialist information
• Most recent glasses and sunglasses
• Picture of contact lens blister/box or CTL RX If your ordered from somewhere else
• Your contact lens case
• List of concerns you would like to discuss with the doctor