Online Patient Form
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Demographics
Patient Information
*
First
*
Last
*
MI
*
Address:
Apt/Suite #:
*
City:
State:
TX
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
UT
VT
VI
VA
WA
WV
WI
WY
ZipCode:
*
Home Phone:
*
Cell Phone:
*
Sex
Male
Female
Contact Method:
Home Phone
Work Phone
Cell Phone
Other Phone
Text Message
Email
*
Email
Referred By:
*
Birthday
Occupation
Billing Information
Is The Billing Address the Same?
First
Last
MI
Address
Apt/Suite #
City
State
ZipCode
TX
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
UT
VT
VI
VA
WA
WV
WI
WY
Home Phone:
Medical Insurance
Insurance Information
*
Employer that provides insurance coverage:
*
Medical Insurance Name: - Click "None" Or "Self-Pay' If You Dont Have Insurance
None
Aetna
All Savers
Ameritas
Avesis
Block Vision of Texas
Blue Cross Blue Shield Texas and other BCBS
Care N Care
Champs Va
Cigna
Cigna International
Davis Vision
ECHO HEALTH
Eyemed
Eyemed Attn: OON Claims
Eyemed Discount Plan
GEHA
Health Partners
Humana
Humana Vision Care Plan (VCP)
Key Benefits Administrators
Medical Eye Services
Medicare Part B
Medxm
Oxford Health Plan
PacificSource Community Solutions
PHCS
Secondary Medicare Gap Supplement
Self Pay-(No Insurance)
Spectera
Superior Vision
Tricare
Tricare East Humana Military
TriWest Healthcare Alliance/WPS
UMR
United Healthcare
United Healthcare Shared Services
VSP
Insurance ID:
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
Vision Insurance Information
*
Insurance Name: - Click "None" Or "Self-Pay' If You Dont Have Insurance
None
Aetna
All Savers
Ameritas
Avesis
Block Vision of Texas
Blue Cross Blue Shield Texas and other BCBS
Care N Care
Champs Va
Cigna
Cigna International
Davis Vision
ECHO HEALTH
Eyemed
Eyemed Attn: OON Claims
Eyemed Discount Plan
GEHA
Health Partners
Humana
Humana Vision Care Plan (VCP)
Key Benefits Administrators
Medical Eye Services
Medicare Part B
Medxm
Oxford Health Plan
PacificSource Community Solutions
PHCS
Secondary Medicare Gap Supplement
Self Pay-(No Insurance)
Spectera
Superior Vision
Tricare
Tricare East Humana Military
TriWest Healthcare Alliance/WPS
UMR
United Healthcare
United Healthcare Shared Services
VSP
Insurance ID:
(VSP ID Number is the Last 4 of Primary SSN)
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
Medical History
*
Reason for Visit:
Secondary Reasons:
Please check if you have these symptoms or past conditions:
Red Eyes
Watery Eyes
Burning Eyes
Dry Eyes
Itchy Eyes
Painful Eyes
Discharge/Build up in Eyes
Stye/Swollen Eyes
Feels like something in eye
Flashing Lights
Floating Spots
Suddenly Blurred Vision
Cataracts
Mascular Degen (Past or Present)
Freckle/Hole/Tear in the back of the eye
Please check if you do not take any medications.
Drug Allergies:
No Known Drug Allergies
Name of Primary Care Doctor:
Office Name and City:
*
Family History Unknown
You
Mom
Dad
Sibling
None
*
Diabetes:
*
High BP:
*
Thyroid Disease:
*
Heart Disease:
*
Cancer:
Eye History
Last Eye Exam:
By Doctor:
You
Mom
Dad
Sibling
None
*
Glaucoma:
*
Macular Degen:
*
Retinal Disease:
*
Cataracts:
*
Lazy/Crossed Eye:
Eye Injury/Surgery/Laser:
Other Eye History:
Interested in contacts?:
Have you worn contacts lenses in the past? What type of contacts have you worn or are currently wearing?:
Visual Tasks
Night Driving
Travel/Drive for Work
Go In/Out Buildings
Occasional Computer Use/Reading
Rigorous Computer Use/Reading
Do you wear glasses?:
I don't wear glasses
I sometimes wear glasses
I wear glasses all the time
I most wear contact lenses
Type of Glasses that you have at home:
Single Vision Distance
Single Vision Reading
Over The Counter Readers
Progressives - Regular
Progressive - Computer
Sunglasses-Progressives
Sunglasses-Single Vision Distance
Line Bifocal
Where last glasses were bought:
Family members that wear contacts/glasses:
Acknowledge and Submit
PT ACKNOWLEDGEMENTS
1) FINANCIAL RESPONSIBILITY/Medicare ABN
I (the patient/responsible member) understand that:
Professional fees will be submitted to patient's vision and/or medical insurance. Patients will be billed for any un-met deductibles, co-insurance, etc. I authorize the payment of insurance benefits to this service provider. I agree to be financially responsible for any balance not paid by my insurance plan. I understand that professional fees are non-refundable.
Routine eye exams with refractive
(well) reasons for visit
will be billed to patient or to patient's medical or vision insurance carrier that the doctor's office participates in.
Eye exams with
medical (sick) reasons for visit
will be billed to patient or to patient's medical insurance carrier that the doctor's office participates in.
Contact lens evaluation
includes f/u contact lens evaluation for about 60 days. Any f/u past 60 days will be charged $50 and for any evaluation past 6 months will need a new evaluation.
Medicare Part B ABN.
Medicare does cover exams a medical evaluation of the eye at 80% coverage. Either you or your secondary insurance will be responsible for the 20% coverage or the $183 part B deductible if not met. Medicare does not cover refraction or wellness eye check.
2) HIPAA
I understand that under the Health Insurance Portability and Accountability Act (HIPAA), I have certain rights to privacy regarding my protected health information. I acknowledge that I have have been given the opportunity to receive a copy of the Notice of Privacy Practices and that I may contact the practice at any time to obtain a current copy of the Notice of Privacy Practices.
3) IMPORTANCE OF RETINAL EVALUATION
Your eyes are one of the few places in your body where your micro vessels can be seen non-invasively. Evaluation of the peripheral retina (micro vessels of the eye) is important and if not evaluated potentially sight threatening eye conditions such as eye diabetes, macular degeneration, retinal detachments, glaucoma, eye tumors etc. can go undetected.
Therefore, all our patients are evaluated via the 2 minute Optomap retinal imaging unless a waiver is signed declining it.
Wellness Optomap imaging is not a fully covered service with most insurances including Eyemed and VSP and has a $39 copay.
Optos Retinal Imaging
(2 mins)
No blurry vision
No Light Sensitivity
Takes less than two minutes
Permanent digital image
Dilation Drops
(25 mins)
Blurry vision 3-5 hours
Light Sensitive 4-6 hours
Adds an additional 25 mins to visit
No permanent record of retina
I release 2020 Eye Dr and the examining optometrist from any liability if my decision is not to return
or to not evaluate my peripheral retina or the retina of the person that I am the responsible adult for.
Signature:
Date:
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