Online Patient Form

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Demographics


Patient Information
TitleFirstLastMISuffixNicknamePronoun
Address Apt/Suite #:
City: State: ZipCode:
Home Phone: Work Phone:
Other Phone: Email
Cell Phone: Preferred Contact:
Birthday: Occupation
Sex Employment Status
Marital Status Employer / School Name
General Physician Parent/Guardian

Billing Information Is The Billing Address Different?
TitleFirstLastMISuffix
AddressApt/Suite #
CityStateZipCode
Home Phone:
Work Phone:

Medical History


Patient History
Please list the main reason(s) for your visit (ie: Check up, Diabetic eye exam, problems seeing far objects, new glasses or contacts, red eyes, etc)


Do you have a history of any of the following?

YESNO
Cataracts:
Eye Turn (Strabismus):
Glaucoma:
Keratoconus:
Lazy Eye (Amblyopia):
Macular Degeneration:
Retinal Detachment:
See Flashing Lights/Floaters:
Dry Eyes:
Poor Night Vision:
Headaches:
Considerable Computer Work:
Previous Eye Infection/Injury:
Problems with Glare:
Double Vision:
YESNO
Diabetes:
High Cholesterol:
High Blood Pressure:
Allergies/Hay Fever:
Arthritis:
Asthma:
HIV+:
Currently Pregnant:
Migraines:
Stroke:
Thyroid Problems:
Cancer:
Other Disease?: If yes, what disease?:




Current Vision Problems:
No vision problems
Far blur without glasses/contacts
Far blur with glasses contacts
Near blur without glasses/contacts
Near blur with glasses/contacts
When was your last eye exam?


Please list all prescription and non-prescription medications you are taking, including eyedrops:
No current medications

Please list any allergies to medicines or environment:
No known allergies

Family History
Family history is unknown/adopted

YESNO
Poor Vision:
Blindness:
Eye Turn (Strabismus):
Lazy Eye (Amblyopia):
Glaucoma:
Cataracts:
Macular Degeneration:
Retinal Detachment/Disease:
YESNO
Cancer:
Diabetes:
High Blood Pressure:
Stroke:
Thyroid Disease:
Other Inherited Disease:
If yes, what disease?

Social History
How often do you consume alcohol:
How often do you smoke/use tobacco products?

Contact Lens Information
Contact Lens Wear History:
Approximate wearing time:
Mode:
Days per Week:
Solution:
Comfort Level?

Policies, Consent, and Submit Data


View Privacy Policy

I understand that payment is due when services are rendered unless
other arrangements have been made. I authorize Mill Run Vision Center
to submit insurance on my behalf, and I accept responsibility for any
unpaid or denied balance from my insurance company. I acknowledge
that I have read and understand Mill Run Vision Center's privacy policy.

You can find a printable copy of this notice on our website.

Initials of Patient (or Guardian if under 18 years):


You're Done! Click below to Submit.

Mill Run Vision Center Privacy Notice

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. This notice is effective 02/25/2016 until further notice.

Right to Notice as a Patient

You have the right to adequate notice of the uses and disclosures of your protected health information. Under the Health Insurance Portability and Accessibility Act (HIPAA), Mill Run Vision Center can use your protected health information for treatment, payment and health care operations.

a) Treatment - We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

b) Payment - We may use and disclose your health information to obtain payment for services we provide you.

c) Health care operations - We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competency or qualifications of healthcare professionals, evaluating provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization

Most uses and disclosures that do not fall under treatment, payment, or health care operations will require your written authorization. Upon signing, you may revoke your authorization in writing through our practice at any time.

Emergency Situations

In the event of your incapacity or an emergency situation, we will disclose health information to a family member, or another person responsible for you care, using our professional judgment. We will only disclose health information that is directly relevant to the person's involvement in your healthcare.

Marketing

We will not use your health care information for marketing communications without your written authorization.

Required By Law

We may also use or disclose your health information when we are required to do so by Law.

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 victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your or other people's health or safety.

National Security

We may disclose the health information of Armed Forces personnel to military authorities under certain circumstances. We may disclose health information to authorized federal officials required for lawful intelligence, counterintelligence and other national security activities. We may disclose health information of inmates or patients to the appropriate authorities under certain circumstances.

Appointment Reminders

We may use or disclose your health information to provide you with appointment reminders via phone, e- mail or letter.

Your Rights as a Patient

You have the right to restrict the disclosure of your protected health information (in writing). The request for restriction may be denied if the information is required for treatment, payment or health care operations. You have the right to receive confidential communications regarding your protected health information. You have the right to inspect and copy your protected health information. You have the right to receive an account of disclosures of your protected health information. You have the right to a paper copy of this notice of privacy practices.

Mill Run Vision Center is required by law to maintain the privacy of your protected health information. We are required to abide by the terms of this notice as it is currently stated, and reserve the right to change this notice. The policies in any new notice will not be in effect until they are posted to this site, or are available within our office.

If you have complaints regarding the way our protected health information was handled, you may submit a complaint in writing to our office. You will not be retaliated against in any manner for a complaint

For More Information

For further information about Mill Run Vision Center's privacy policies, please contact Dr. Michael Schecter at the following address or phone number:

Mill Run Vision Center
3716 Fishinger Blvd.
Hilliard, Ohio 43026
614-876-1766.

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