Online Patient Form

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Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other 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
Primary Care Doctor
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Vision Insurance 1

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:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision Insurance 2

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:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision Insurance 3

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:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical Insurance 1

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:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical Insurance 2

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:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Privacy Policy

Privacy Policy Privacy Policy NOTICE OF PRIVACY PRACTICES 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. OUR LEGAL DUTY 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. We reserve the right to change 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 the changes. In the event we make an important change in our privacy practices, we will change this notice and make the new notice available upon request. USES AND DISCLOSURES OF HEALTH INFORMATION 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 doctors, nurses, technicians, medical students, or other people who are taking care of 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. Health Care Operations: We may use and disclose your health information in connection with our healthcare operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certification, licenses and credentials we need to serve you. Marketing Health Care 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 care information. To Family and Friends: We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or payment for your healthcare, if you agree that we may do so or, if you are not able to agree, if it is necessary in our professional judgment. 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. 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. Appointment Reminders & Treatment Alternatives: We may use or disclose your health information to provide you with appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. PATIENT RIGHTS 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 your request in writing. You may get the form to request access by using the contact information listed at the end of this notice. You may also request access by sending a letter to the contact person listed 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 request copies we will charge you $ 0.50 for each page, and postage if you want the copies mailed to you. 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 and other specified exceptions. 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 Web site or by e-mail and wish to receive a paper copy, you have the right to obtain a paper copy by making a request in writing to the Privacy Officer at our office. QUESTIONS AND COMPLAINTS 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 you may complain to us using the contact information listed at the end of this notice. You may also 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. We will not retaliate in any way if you choose to file a complaint. Contact Person: Lawrence Wang, O.D. - Privacy Officer Telephone: 702-220-3937 Fax: 702-655-3182 Address: 7090 N. Durango Blvd. #110, Las Vegas, NV 89149
I have read and understood the Centennial Family Eyecare Privacy Policy. >

Enhanced Testing

Advanced Testing
I would like an advanced digital retinal photogrpaph ($39) that helps the doctor detect early eye disease? (yes or no)
I would like to be screened by our skin caratenoid bioscanner to measure macular degeneration risk? ($30)(yes or no)
I would like a high definition OCT ultrasound of your optic nerves to measure glaucoma risk? ($30)
Yes or No

Medical History

Welcome to Centennial Family Eyecare: Dr. Lawrence Wang & Associates
Today's Date
Where was your last eye exam?
When was your last eye exam?
What is your Occupation?
Do you have any hobbies?
What is your preferred Nickname?
Patient since:
What is your Date of Birth:
Is there any eye disease in the family?:
Ethnicity:
Prefered Language
Primary Care Physician & Other physician Names
What is the purpose of your visit today?
Do you have any Secondary Complaints?
What is your contact lens history?
Have you had any Eye Surgeries?
Other Surgeries:
Do you have any drug allergies?
What Medications are you taking?
What Other medications are you taking?
Who Referred you today?
I have read and understood the Centennial Family Eyecare Privacy Policy.
I would like to receive text messages from Centennial Family Eyecare.
Phone Number:
The following person(s) are allowed to pick up my prescriptions and materials.
Name & Phone Number:

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