Online Patient Form

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Patient Information


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name

Emergency Contact Name & Phone Number

Billing Information

Is The Billing Address the Same?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:


Primary

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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision

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:
Sex:
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!

Eye History

Reason for Visit: Secondary Reasons:

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:

Medical History

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

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing: Recent Tetanus Shot: Recent Flu Immunization:


Do you have any of the following problems?:

Problem 1:
Problem 2:
Problem 3:
Problem 4:
Problem 5:
Problem 6:

Family Medical History


Please describe your family medical history in the sections below.



Family Medical History (Adopted, Diabetes, High Bloop Pressure, Cancer, Lupus, Thyroid, Cardiovascular Disease etc)
Family Medical History 2 (Diabetes, High Bloop Pressure, Cancer, Lupus, Thyroid, Cardiovascular Disease etc)
Family Medical History 3 (Diabetes, High Bloop Pressure, Cancer, Lupus, Thyroid, Cardiovascular Disease etc)
Family Medical History 4 (Diabetes, High Bloop Pressure, Cancer, Lupus, Thyroid, Cardiovascular Disease etc)
Family Medical History 5 (Diabetes, High Bloop Pressure, Cancer, Lupus, Thyroid, Cardiovascular Disease etc)
Family Medical History 6 (Diabetes, High Bloop Pressure, Cancer, Lupus, Thyroid, Cardiovascular Disease etc)

Family Eye History

Does anyone in your family have any of these eye conditions?:

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:

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

Race: Ethnicity: Preferred Language:

Submit Form / Patient Signatures



NOTICE OF PRIVACY PRACTICES AND METHODS OF PAYMENT

No Medical Insurance or Vision Plan?

No problem! Optopia - Ramer Eye Care offers a discount for all non-insurance patients for their vision or medical exam. We save some money from time and fees when filing an insurance claim, and we pass this savings on to you with our non-insurance discount. We also accept all major credit cards, cash, or checks.

Vision Plans

Some vision insurance plans do not provide an insurance card. Vision plans usually include benefits towards glasses or contacts. (Examples: VSP, EyeMed, Avesis, Superior Vision, etc.). Medical insurances generally do not cover these vision benefits.

Major Medical Insurance and/or Medicare

We keep your medical insurance information on file because we perform medical eye care. Your medical insurance plan covers for infections, foreign body removals, eye disease, treatments, etc. Refractions (checking vision) and the contact lens portion of the exam are not generally covered by medical plans. We will file your medical insurance on your behalf, but this does not guarantee payment and any remaining balance will be paid by you. If your deductible has not been met for the year, you will be responsible for services rendered.

INFORMED CONSENT & TREATMENT AUTHORIZATION

The law requires that we make every effort to inform you of your rights related to your personal health information.

  • I acknowledge that I have read or have had the opportunity to read the Notice of Privacy Practices for Dr. Greg Ramer and Dr. Neill Clem.
  • I authorize Dr. Greg Ramer, Dr. Neill Clem, or the staff to leave a message with available persons at my home phone number, on my answering machine or with the emergency contact listed.
  • I hereby authorize Dr. Greg Ramer and Dr. Neill Clem to provide a diagnosis & optometric treatment to my child or me. I further authorize the release of Protected Health Information to additional physicians or optometrists in order to facilitate continuity of care.


FINANCIAL & INSURANCE FILING POLICY

  • Payment for copay and/or deductible is due at the time services are rendered.
  • All charges are your responsibility, whether or not your insurance company pays. Not all services are covered in all contracts. Some insurance companies arbitrarily select certain services they will not cover. We cannot become involved in disputes between you and your insurer regarding covered charges, deductible, or copay.
  • If your insurance company does not pay your claim, it is your responsibility to contact them to expedite payment. If your insurance company refuses to pay, you are responsible for payment.
  • We accept cash, checks, money orders, and most major credit cards.
  • Canceled or rescheduled appointments are subject to a fee if we do not receive 24 hours advance notice.
  • In the event that the refraction is not covered by your insurance, you will be charged a fee in addition to your copay and/or deductible.


AUTHORIZATION TO RELEASE HEALTH INFORMATION & ASSIGN BENEFITS

I authorize the release of all necessary Protected Health Information & assign all medical & vision benefits to Dr. Greg Ramer and Dr. Neill Clem. I also request that payment of authorized Medicare (if applicable) benefits be made on my behalf to Dr. Greg Ramer and Dr. Neill Clem for any services furnished to me by the doctor. I authorize any holder of medical information related to me to release to the Centers for Medicare & Medicaid Services (CMS) & its agents, any information needed to determine these benefits or the benefits payable to related services. I understand that my signature requests that payment be made & authorizes release of medical information necessary to pay the claim. If item 12 of the CMS 1500 claim form is completed, my signature authorized releasing of the information to the insurer or agency shown. In Medicare assigned cases, the supplier agrees to accept the charge determination of the Medicare carrier as the full charge, & the patient is responsible only for the deductible, copay, & non-covered services. Copay & deductible are based upon the charge determination of the Medicare carrier. I understand that I am ultimately responsible for any bill incurred in this office. Should this account become delinquent, I will be responsible for any & all legal fees, court costs, & collection charges. There will be a service charge for each returned check. This authorization & assignment will remain in effect until revoked by me in writing. A photocopy of this authorization & assignment is to be considered as valid as the original. I request that you file my insurance & I have agreed to & completed all of the conditions listed above. I accept financial responsibility for all charges.

ABOUT YOUR INSURANCE

There are two types of health insurance that will help pay for your eye care services and optical products. You may have both types and Ramer Eye Care Center accepts most insurance plans in both categories: Vision plans (such as VSP, EyeMed and others) and Medical insurance (such as Blue Cross/Blue Shield, United Health Care, Medicare and others).

  • Vision plans cover only the routine vision wellness exams, along with eyeglasses and contact lenses. Vision plans do not cover medical eye care (the diagnosis, management or treatment of eye health problems).
  • Medical insurance must be used for medical eye care.
  • If you have both types of insurance plans it may be necessary for us to bill some services to one plan and some services to the other. We will follow a procedure called coordination of benefits to do this properly and to minimize your out-of-pocket expense.
  • If some fees are not paid by your insurance, we will bill you for them, such as deductibles, co-pays or non-covered services as allowed by the insurance contract.


PURCHASE POLICY

We pride ourselves in giving great service to our patients. Our office hopes that you will be satisfied and happy with our service and products. However, all lenses and contacts are medical devices with custom fittings and manufacture. These items are designed especially for you and may not be refunded. The information below outlines our office policy concerning the sale of glasses and contact lenses.

Glasses

We require at least half of the balance to be paid before an order is processed. If you are not completely satisfied with your RX or frame within 30 days, we will check the RX and go over the order to make sure all components are as represented at the time of purchase. If a change is needed based on the RX or lab error, the lenses will be remade at no charge. If you decide to add or change any lens feature the applicable charge will be required. If you have an issue with the frame, a new frame may be chosen within 30 days. If new lenses are required there will be additional charges. All frames have a 1 year warranty toward manufacturer defects excluding nose pads. Warranty frames will be supplied with a $10.00 administration fee. Warranty lenses will be supplied with a $5.00 administration fee.

Remakes will always be considered unless one of these exceptions is present: RX is affected by physiological diagnosis (diabetes, medication, etc.) or the RX has come from an outside Optometrist/Ophthalmologist or 3rd party vendors (optical chain stores, internet sales, etc.) Please be advised that we will remake your glasses one time if it is a lab or doctor error and if it is reported within the 30 day time frame. If you are still unhappy with the result, then the second remake will be at your own expense.

Non-RX sunglass purchases are non-refundable. Only store credit will be given.

Adjustments and repairs to patients own frame are gladly done at your own risk. However, in the event of a breakage, you will be given a 15% courtesy discount off the retail value if you wish to replace them in our office.

Contact Lenses

All contact RX's are verified with trial fittings before ordering contacts. We will accept returns on unopened boxes within 60 days of purchase for full credit. Opened boxes are not exchangeable. All materials (contact lenses, frames, and lenses) left in our office over one year will be donated to charity. Any other issues will be handled on a case by case basis. You will be required to approach the office within (14) business days of dispensing for the above polices to be in effect.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

Please check, sign, and date that you have read and agree to our policies and click the SUBMIT button to complete your online forms. Thank you!

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