Online Patient Form

Click here to return to the the previous website.

After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Fields marked with a * are required.

Demographics


Patient Information
Title*First*Last*MISuffixNickname
Address:*
City:* State:* Zip Code:*
Home Phone:* Work Phone:
Other Phone: Alerts:
Cell Phone:* Preferred Contact Method:
SSN Email*
Birthday* Occupation*
Sex* Employment Status
Marital Status Employer / School Name
Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Medical Insurance

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

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 History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!


Reason for Visit:* Secondary Reasons:

Medications:* Over The Counter Medications:*
Vitamins:* Drug Allergies:*
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant: Breast Feeding:

Family Medical History*



Do you or anyone in your family have these medical conditions?

Diabetes: Type: Year Diagnosed: HbA1C:
High Blood Pressure: Describe:
High Cholesterol: Describe:
Thyroid Disease: Describe:
Heart Problems: Describe:
Cancer: Describe:

Eye History

Do you currently have any of these symptoms?:*
Do you take any of these eye medications?:*
Last Eye Exam: By Doctor:

Primary Vision Correction:
Do you:    Have back up glasses? Want new glasses?

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time: Days per week worn: Hours per day worn:

Family Eye History*

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Lazy/Crossed Eye:

Review of Systems*

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

Social History

Hobbies: STD's:

Smoking Status:* Type: How Long:
Alcohol Use:* Type: How Long:
Illegal Drug Use:* Type: How Long

Race: Ethnicity: Preferred Language:

Privacy Practices

Effective date of notice: July 1, 2003

NOTICE OF PRIVACY PRACTICES

1101 S. Joyce St., Suite B7
Arlington, VA 22202
703-418-2020
Neeraj Bindal, O.D.
1150 Connecticut Ave, #107
Washington, DC 20036
202-466-3888
______________________________________________________________________________________

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.

______________________________________________________________________________________

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.

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 faxing them to be filled; showing you low vision aids; referring you to another doctor or clinic for eye care or low vision aids or services; or getting copies of your health information from 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 (either ourselves or through a collection agency or attorney). "Health care operations" mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for 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 of 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 will apply to us; some may never come up at our 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 subpoenas or orders of 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 a 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 and disclosures to prevent a serious threat to health or safety;
  • uses or disclosures for specialized government 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 relating to worker's compensation programs;
  • 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 or 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 you with your eye care.

APPOINTMENT REMINDERS

We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call you at the numbers you provided to us or write to 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 card, and/or leave you a reminder message on your answering machine or with someone who answers your phone.

ORDER CONFIRMATION

We may call or write to confirm orders placed by you or to provide status of orders. Unless you tell us otherwise, we will make contact by mail and/or at the numbers you provide to us, whether it be with you, by leaving you a message on your answering machine or with someone who answers your phone.

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's 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 one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this Notice.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

The law gives 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 operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the office contact person at the address shown at the beginning of this Notice.
  • ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using E mail to your personal E Mail address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office contact person at the address shown at the beginning of this Notice.
  • ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address shown at the beginning of this Notice.
  • ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to. persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office contact person at the address shown at the beginning of this Notice.
  • get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or 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 you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office contact person at the address shown at the beginning of this Notice.
  • get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written request to the office contact person at the address 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 we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our Web site.

COMPLAINTS

If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.

FOR MORE INFORMATION

If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this Notice.

ACKNOWLEDGEMENT OF RECEIPT

I acknowledge that I received a copy of A Visual Affair's Notice of Privacy Practices.

Signature:* Date:*

Submit Form

A Visual Affair

VISUAL FIELDS AND RETINAL IMAGING EXAMINATIONS

A new, sophisticated computerized instrument allows us to provide a more thorough medical analysis of your eyes. Our HUMPHREY FDT VISUAL FIELD ANALYZER electronically measures retinal function and sensitivity to light. This procedure not only assesses the central and peripheral fields of vision, but the function of the retina, optic nerve, and visual pathways.

The TOPCON RETINAL CAMERA allows us to take an image of your retina. This technology helps the doctor evaluate the appearance and health of the back of the eyes and serves as a baseline for future comparison.

These two instruments assist in the early detection of many disorders including glaucoma, diabetic retinopathy and brain tumors. When detected early, treatment is more effective and vision loss and even death itself may be prevented.

Dr. Bindal recommends that all of his patients receive these tests. The Visual Field is highly recommended at every annual visit and the retinal photos at least every two years. These tests are especially important for people who have:

  • 1. Headaches
  • 2. Family history of Glaucoma
  • 3. See spots or flashes of light
  • 4. A history of diabetes
  • 5. A history of high blood pressure
  • 6. Circulation problems
  • 7. A strong eyeglass prescription
  • 8. Reached the age of 25

These screening tests are optional. There is an additional charge of $20.00 for each test or $30 for both tests. Under certain circumstances, these tests may be medically necessary. If so, your insurance company may pay for the full medical test(s).

Please check the appropriate line below and sign at the bottom.*





Signature:* Date:*


A Visual Affair

Dr. Neeraj Bindal, Optometrist

Pentagon Row
1101 S. Joyce Street, Suite B7
Arlington, VA 22202
(703) 418-2020
(703) 418-2122 (Fax)
DuPont Circle
1150 Connecticut Ave, Suite 107
Washington, DC 20036
(202) 466-3888
(202) 466-2488 (Fax)

FINANCIAL & COMMUNICATION CONSENT

COMMUNICATIONS WITH YOU AND CONSENT TO CONTACT YOU

I, *, agree to be financially responsible for the charges for these services. If my account is assigned to a collection agency, I agree to pay all collection fees of 25%, court costs and reasonable attorney fees. I understand that all accounts with a balance over 30 days will be assessed interest at the rate of 18% annually on the unpaid balance.

In addition, you agree, in order for us to service our account or to collect any amounts you may owe, we, our agents, assignees, third party(s) or servicing agent(s) may contact you by telephone at any telephone number associated with your account and/or number you provided by you, including wired or wireless telephone numbers, which could result in charges to you. Your also agree all to allow us, our agents, assignees, third party(s) or servicing agents to communicate with you to include text messaging, e-mail, facsimile, and any other electronic communications You also agree that Methods of contact may include the use of pre-recorded/artificial voice messages and/or use of an automated telephone dialing device or system, as applicable. You agree that we, our agents, assignees, third party(s) or servicing agent(s) may, for training purposes or to evaluate the quality of service, may listen to and record phone conversations you have with us and/or our agents, assignees third party(s) or servicing agent(s).

Signature:* Date:*













Office Policies

Return / Exchange / Credit / Office Policy

Professional Fees - No refunds. Contact lens exam includes routine contact lens follow up care for up to 60 days from date of exam, after which any visits will be charged. Contact lens care after 6 months from date of exam will require a new comprehensive exam and a new contact lens evaluation. We recommend that you pick up your trials as soon as possible and schedule your follow-ups in a timely manner. Eye infections, 'pink eye', etc., are not considered routine visits. Routine glaucoma check and dilation not performed at the initial exam visit should be completed within 30 days from date of exam to avoid additional charges.

Missed appointments - Our appointments are specially catered to the needs of our clients. As our clients are important to us, so are our appointments. Thus, we reserve the right to bill any client for missing an appointment without 24 hours notice.

Insurance - We are happy to obtain insurance benefit information on your behalf. However, we can not be held liable in the event the information is incorrect or a miscommunication occurs, as insurance companies have a disclaimer that benefit information is not a guarantee of payment until the claim is actually made. Clients are responsible for knowing their coverage, as well as paying the balance for any services or products not paid by the insurance company.

Contact Lenses - Unopened, unmarked and undamaged boxes can be exchanged within 7 months from order date. Returns and cancelled orders are subject to a 10% restocking fee, minimum of $10. Rigid Gas Permeable lenses must be returned within 30 days from the day the lens are ready for pick up. Prescriptions are not released for any custom made lenses.

Sunglasses (Non-prescription)& Readers - No refund, exchanges or store credit.

Frames - Eyeglass frames are refundable within two weeks of purchase ONLY if in ORIGINAL condition, including case, subject to a 10% restocking fee. Store credit may be given if returned within 4 weeks. The staff is glad to make recommendations but the ultimate frame choice is the client's. Please make sure you are comfortable with your eyewear before purchasing. Frames come with a six month warranty against any manufacturer defects. There is NO warranty on ready-made readers, or store "specials" e.g. $99 package, $149 package as these are discontinued models and parts are not available.

Patient-owned Frames - While we are happy to adjust your frames or replace new lenses in them, A Visual Affair, nor any of its employees can take responsibility for accidental damage, breakage or lost frames. It is at the patient's own risk.

Ophthalmic Lenses - Lenses are custom made to your prescription. Therefore, we cannot offer refunds, exchanges, or credits. If there is any error, whether it be prescription or lab, we will correct and resolve the error as quickly as possible. Any job that is redone due to a fault in our prescription or lab will be done at no cost to you, in the same frame within 60 days from the time they are ready for pick-up; refunds will not be provided. Lenses that must be redone for an incorrect outside prescription will be done at 50% of the original full retail cost. Any cancellations made once the order is placed, but before the work has begun, will incur a 10% fee. Any coatings applied to lenses come with a manufacturer's warranty against any manufacturer's defects. Any coatings, including scratch coatings, can still be scratched, and may not be covered. Chipped lenses are covered for 30 days from time glasses are ready for pick up. For tinted lenses, please be informed they are made to the best possible match, therefore, no guarantee can be made.

* Progressive lenses come with a 30 day non-adapt warranty which starts the day the order is ready to be picked up. Patients unable to adapt to progressives can exchange their lenses for single vision or bifocal lenses at no additional charge. Any Progressive Lens Design change is limited to one re-do, therefore we recommend to try the initial progressive lens design for two weeks before making changes. Refund or difference in price will not be provided. All other lenses (single vision, bifocals, polarized, sunglasses, office/computer lenses, etc) do not come with a non-adapt warranty.

* * * * * * * * * * *


Knowing how important your sight is to you, we make every effort to get your order to you as soon as possible. However, events may occur that may delay an order, such as breakage, improper lens fitting or back order. Please keep in mind that all dates given are estimates, and therefore cannot be considered contractual.

* * * * * * * * * * *


For orders left over 90 days, we can not take responsibility, nor can we offer any refunds. We appreciate your understanding of our office policies.

*Signature:    *Date: