Online Patient Form

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

Patient Information


TitleFirstLastMISuffixNickname
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:
City: State: Zip Code:
Home Phone:
Work Phone:

Vision Insurance Information

Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account:
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical 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!

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 Or Nursing: Recent Tetanus Shot: Recent Flu Immunization:


Do you have any of these medical conditions? If yes, please describe:

Diabetes: Year Diagnosed:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Family Medical History



Does anyone in your family have any of these medical conditions? If yes, please describe:

Diabetes:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Eye History

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Have you had any eye surgeries? Please describe:
Last Eye Exam: By Doctor:

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

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time:

Family Eye History

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

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:

Eye X Care 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.



Eye X Care is required by law to maintain the privacy of your health information, to follow the terms of this Notice, and to provide you with this Notice of its legal duties and privacy practices with respect to your health information. We will not use or disclose medical information about you without your written authorization, except as described in this Notice. We reserve the right to change our practices and this Notice and to make the new notice effective for all medical information we maintain. Upon request, we will provide a written copy of this Notice to you.

How Eye X Care May Use or Disclose Your Health Information

Eye X Care protects the privacy of your information. The law permits Eye X Care to use or disclose your health information for the following purposes:
  • Treatment, Payment and Regular Health Care Operations- Information obtained by the facility location will be used to dispense and provide prescription opthalmologic goods and services to you, bill your insurance carrier if you have third party coverage, and to record and monitor the service provided to you. Information will also be provided to you upon your request.
  • As and When Required by Law- We may use and disclose your health information to Public Health Officials, Law Enforcement, Health Oversight Activities (for audits, investigations, etc.), judicial and Administrative, Deceased Person Information, Workers Compensation programs, Food and Drug Activities (FDA for reporting of adverse drug events and quality issues), if there is a serious threat to your health or safety, in times of National Security, if you are in the military or a veteran of the armed forces when requested, or if you become an inmate in a correctional facility.
  • Personal Communications- We may contact you to provide appointment reminders, annual eye examination post cards, and other information about treatment or other health-related benefits and services that may be of interest to you as well as communicate with individuals involved in your care of payment for your care.
  • Disclosure to Our Business Associates- There are some services provided by us through contracts with business associates. When these services are contracted, we may disclose health information about you to our business associates so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information, we require the business associate to appropriately safeguard the health information.
  • Victims of Abuse, Neglect, or Domestic Violence- We may disclose your health information to a government authority, such as social services or protective service agencies, if we reasonably believe you are a victim of abuse, neglect, or domestic violence.
  • Marketing Communications- We must obtain your written communication authorization prior to using your health information to send you and marketing materials. We may communicate with you about products or services relating to your treatment, care, or alternative treatments, or providers without authorization.

When Eye X Care May Not Use or Disclose Your Health Information

Except as described in this Notice of Privacy Practices, Eye X Care will not use or disclose your health information without written authorization. If you do authorize Eye X Care to use or disclose your health information for another purpose, you may revoke your authorization in writing any time. If State law provides additional restrictions upon any of the foregoing uses and disclosures, we must follow the state law.

You Have the Following Rights With Respect to Your Health Information

You have the right to request restriction on certain uses and disclosures of your health information. To make such requests, you must complete the Restriction of the Use of Patient Information form and the request will only apply to the location providing the service. Eye X Care is not required to agree to the restriction(s) that you have requested.

You have the right to inspect and copy your health information as long as we maintain the health information. Your health information usually will include prescription and billing records. To inspect or copy your health information, you must complete a Request to Inspect Medical Records form and submit the request to the location that provided your service.

You have the right to receive an accounting of disclosures of your health information we have made after April 14, 2003 for most purposes other than treatment, payment, health care operations, information provided to you, and certain government functions. To request an accounting, you must complete the Request for Accounting of Disclosure form. You must specify the time period but may not be longer than six years. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time.

You may request communications of your health information by alternative means or at alternative locations. For example, you may request that we contact you about medical matters only in writing or at a different residence or post office box. To request confidential communication of your health information, you must complete a Request for Alternative Communication form that will only be good for the location providing services. Your request must state how and when you would like to be contacted. We will accommodate all reasonable requests.

If you would like to exercise one or more of these rights, contact the location that provided your service or submit a written request to that location.

Eye X Care Optical- Huber Location Address: 6079 Brandt Pike, Huber Heights, OH 45424

Changes to This Notice of Privacy Practices

Eye X Care reserves the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, Eye X Care is required by law to comply with this Notice. The revised notice will be posted in our dispensary for public viewing and will be available upon request.

For More Information or to Report a Problem

If you have questions or would like additional information about the privacy practices, you may contact us at the address above or call (937) 237-8669. If you believe your privacy rights have been violated, you may file a written complains with Secretary of Health and Human Services.

By signing below, I acknowledge that I have received the Privacy Notice.

Signature: Date: