New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone:
Work Phone: Alerts:
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
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Different?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Medical Insurance

Insurance Information Please select Prompt Pay if you do not have Medical Insurance or 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:

Vision Insurance

Insurance Information Please select Prompt Pay if you do not have Medical Insurance or 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:

Tertiary Insurance

Insurance Information Please select Prompt Pay if you do not have Medical Insurance or 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


Please choose from the menu options or select "Other" to type in multiple choices and/or your own text. Thank you!

Any specific concerns that need to be addressed?


Please rate your Health:

Check all conditions that you have been diagnosed with or apply to you?

Diabetes
Hypertension
Cholesterol
Arthritis
Respiratory Prob
Heart Problems
History of Cancer
Kidney Problems
Thyroid Problem
Pregnant
Cigarette Smoker
New Headaches
Glare
Floaters
Light Flashes
Light Sensitivity
Dry Eye
Itching
Environmental Allergies
Eye Surgeries
Macular Degeneration
Glaucoma
Cataracts Surgery
Lazy Eye (Strabismus) Surgery
Retinal Tears or Detachments









Family History
Family History of Glaucoma
Family History of Macular Degen
Family History of Diabetes

Primary Doctor:
Last Health Exam:
Last Eye Doctor:
Date of last Eye Exam:

Systemic Meds:
Medicine Allergies:
Eye Medicine or OTC Eye drops:

Do you participate in any of the following?

Golf Boating Swimming Gardening Hunting Running, Biking, or Triathlons

Policies, Consent and Submit Data


NOTICE OF PRIVACY PRACTICES

Effective Date: April 14th, 2003
Revision Date: November 19th, 2014

This Notice describes how medical information about you may be used and disclosed and how you can obtain access to this information. Please review it carefully

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This notice describes how we protect your health information and what rights you have regarding it.


YOUR RIGHTS REGARDING YOUR HEALTH BENEFITS

The law give you many rights regarding your health information.

You can:

  • Ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operation. To ask for a restriction, send a written request to the office contact person at the address, fax or email shown at the address, fax or email shown at the beginning of this notice.
  • Ask us to communicate with you in a confidential way. We will accommodate these requests if they are reasonable, and if we are reimbursed for any costs we incur to fulfill your request. To ask for confidential communications, send a written request to the office contact person at the address, fax or email shown at the beginning of this notice.
  • Ask to review or to obtain photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying of patient medical records. Generally, you will be able to review or obtain copies of your health information within thirty days of placing your request (or sixty days if information is stored off-site). It is possible that we may have to receive payment for photocopies in advance. If your request is denied, you will receive a written explanation and instructions about how to get an impartial review of our denial if one is legally available. By law, we are allowed one 30 day extension to provide you access or photocopies by sending you a written notice of the extension. To review or receive photocopies of your health information, send a written request to the office contact person at the address, fax or email shown at the beginning of this notice.
  • Ask us to amend your health information if you believe it to be incorrect or incomplete. If we agree, we will amend the information within sixty days of your initial request. We will then send all corrected information to any persons or parties we know to have received the initial health information, and to any others that you specify. If we do not find your health information to be incorrect or incomplete, we will be happy to include a statement of your position in your health information alongside any rebuttal statement. Once your statement of position is incorporated into your health information, it will be included anytime we make a permitted disclosure of your health information. By law, we are allowed one 30 day extension to provide you access or photocopies by sending you a written notice of the extension. To review or receive photocopies of your health information, send a written request to the office contact person at the address, fax or email shown at the beginning of this notice.
  • Obtain a list of the disclosures of your health information that have been made within that past six years. This office is not required to account for disclosures made prior to the effective date. By law, the list will not include: disclosures for purposes of treatment, payment of health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If additional or more frequent lists are required, payment for such lists must be received in advance. Requests are responded to within sixty days of receipt, and we are allowed one thirty day extension which you will be notified of in writing for a list of health information disclosures, send a written request to the office contact person at the address, fax or email shown at the beginning of this notice.
  • Obtain additional paper copies of this Notice of Privacy Practices upon request. For additional paper copies, send a written request to the office contact person at the address, fax or email shown at the beginning of this notice.

OUR NOTICE OF PRIVACY PRACTICES

By law, we must abide by the terms of this Notice of Privacy Practices until any additional revision of this notice become effective. We reserve the right to change this notice at any time, as allowed by law. If changes become effective, they will apply to your health information already on file as well as any information that may be generated in the future. Any changes or revisions to our Notice of Privacy Practices will be posted on our website and in office, with paper copies available upon request.

COMPLAINTS

If you believe we have not properly respected the privacy of your health information, you are free to file a complaint with our office or the United States Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you in response to any complaints filed against us. Any complaints can be discussed in person or by phone, as well as through written complaints submitted through the contact address, email or fax at the beginning of this notice. To review or receive photocopies of your health information, send a written request to the office contact person at the address, fax or email shown at the beginning of this Notice.

TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are; setting up an appointment for you testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and hem to be filled; showing you low vision aids, referring you to another doctor or clinic for eye care or low vision aids or services; obtaining copies of your health information for m 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 (wither ourselves or through a collection agency or attorney.) "Health care operations" mean those administrative and managerial functions that we must do in order to run our office. Examples of how we use or disclose your health information or 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.

We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside our office for these reasons, we usually will not ask you for special written permission.

Uses and Disclosures for Other Reasons without Permission

In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations apply to us; some may never come up at or office at all. Such uses or disclosures are:

  • When a state or federal law mandates that certain health information be reported for a specific purpose;
  • For public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug administration regarding drugs or medical devices.
  • Disclosures to governmental authorities about victims of suspected abuse, neglect, or domestic violence;
  • Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
  • Disclosures for judicial and administrative proceedings, such as in response to subpoena orders or courts or administrative agencies.
  • Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime, to provide information about crime at our office; or to report a crime that happened somewhere else;
  • Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or 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; uses or disclosures for specialized governmental functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
  • Disclosures of de-identified information;
  • Disclosures of a limited data set for research, public health, and health care operations;
  • Incidental disclosures that are an unavoidable by product of permitted uses of disclosures;
  • Disclosures to "business associates' who perform health care operations for us and who commit to respect the privacy of your health information;

Unless you object we will also share relevant information about your care with your family or friends who are helping with your eye care.

Appointment Reminders

We may call, write or electronically remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call, write, or electronically notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a post care, letter, through email, text messaging services, and/or leave you a reminder message on your home answering machine or with someone who answers our phone when you are not home.

Other Uses and Disclosures

We will not make any other uses or disclosures of your health information unless you sign a written "authorization form." The content of an authorization form is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it is your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form or you can use one of ours.

If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign an authorization form, you may revoke it at any times unless we have already acted in reliance upon it. Revocation must be made in writing. Send them to the office contact person named at the beginning of this notice.



CONTACT LENS POLICY

The use of contact lenses is not for everyone so it is not possible to determine in advance whether you will have success with contact lens. Various personal, ocular, and environmental factors may necessitate a change in the recommended wear schedule or termination of lens wear. These factors include, but are not limited to:

-Inability or unwillingness to return for follow-up care
-Not adhering to recommended lens care cleaning instruction and not adhering to prescribed disposal schedule
-Manual dexterity problems that prevent proper lens removal and cleaning
-Dryness of the eye or poor ocular response

Any contact lens wearer can rapidly develop eye problems that can lead to permanent loss of vision.
Risk of complications is increased with overnight wear.
If you experience discomfort, redness, light sensitivity, or blurry vision, remove your contact lenses at once and call our office. Do NOT ignore these symptoms. Do NOT continue wearing your lenses.

Contact Lens Evaluation Fees:

There are separate fees for contact lens evaluation and contact lens material. The contact lens evaluation includes the initial contact lens evaluation, training if necessary, and progress visits within the initial 60 days. Additional visits after 60 days from the contact lens evaluation date will be subject to our usual and customary fee of $45.00 per visit. The additional visits are not covered by insurance.

For Patients with Insurance:

The contact lens evaluation fee may be deducted from your contact lens allowance. If you elect to utilize your insurance benefits towards the purchase of glasses, you will be responsible for the contact lens evaluation fee.

Refund and Exchange Policy:

Your unopened boxes of clear disposable contact lenses may be returned within 30 days of the original dispensing date for full credit. NO REFUNDS, EXCHANGES OR CREDITS ON COLORED CONTACTS AT ANY TIME. There are NO refunds, exchanges or credits on RGP, CRT, Toric or Bifocal/Multifocal lenses for any reason after the initial 30 day evaluation period.
Fees for the exam, contact lens evaluation, contact lens fitting, and services are NOT REFUNDABLE.

Patient Responsibility:

I understand that contact lenses are medical devices and that they are not without risks. I have read, understand, and agree to adhere to the policies, fees, and clinical requirements of Today's Vision contact lens agreement.



FINANCIAL POLICY

Dr. Patel and staff members are dedicated to serving your eye care needs with the best professional advice, care, and service obtainable. If you have any questions during your eye exam today, please feel free to ask.

Private Pay Patients: Full payment is due at the time of service.

Insurance Plans: In order for us to file your medical and vision insurance plans appropriately, we must have a copy of your current medical insurance card and must have the name of your vision insurance plan if applicable. If you do not have your insurance card at the time of service, full payment is due at the time of service. If your comprehensive routine exam is covered by your medical and vision insurance, our clinic's policy is to bill medical insurance first. You are responsible for all co-pays and deductibles.

Filing insurance claims is a service we provide free of charge, but in no way relieves you from the responsibility of your bill.

Please note: It is your responsibility to know your insurance policy rules and benefits. We file claims to many different insurance companies, and it is impossible for us to know your individual insurance policies. Please be aware that some, and perhaps all, of the services provided may be considered by your insurance company to be non-covered services and/or might be subject to a deductible in addition to your co-pay. You have the right to refuse any services rendered to you if you think they are non-covered services or not payable by your insurance company. It is your responsibility to let us know of any insurance changes. Please don't assume that we know your insurance information has changed.

Missed Appointments & Miscellaneous Services:

Appointment times are reserved exclusively for the scheduled patient. We do not double book appointments because Dr. Patel believes you deserve our undivided attention. By giving us 24-hour notice of appointment changes or cancellations, other patients who need our time and care can be appointed.

If 24-hour notice is not given, a $50.00 charge for examinations will be billed to the patient.

Non-sufficient Funds Check Fee is $50.00. All outstanding accounts turned over to a collection agency will be assessed an additional charge of $50.00.

I understand and agree to this financial policy. I have read the financial policy and agree that a photocopy of the financial policy shall be considered as effective and valid as the original. Regardless of what insurance coverage I have, I am ultimately responsible for the timely payment of my account and I hereby authorize the payment of insurance benefits to be made directly to Today's Vision.


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