Online Patient Form

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Patient Information

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Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
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Billing Information

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Medical History

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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:

Family Medical History

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

High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:

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:

Social History

Hobbies: STD's:

Smoking Status:
Alcohol Use:
Illegal Drug Use:

Preferred Language:

Submit Form / Signatures

Greetings! We're so happy to have you schedule with us at Insight Vision Care. We would love to have you read the following document and provide us with your signature at the bottom. Please don’t hesitate to reach out if you have any questions or concerns, and we'd be happy to help. Thanks again and we look forward to seeing you soon!

Assignment Of Medical Benefits

(1) Comprehensive eye exams include all professional services related to the evaluation and treatment of your eye and visual health. In particular, routine eye exams (i.e., presenting only with symptoms of blurred vision, without any acute / chronic eye health conditions / diseases) and refractions (i.e., the determination of your eyeglass prescription) are usually covered by vision insurances, but NOT primary health insurances. (MEDICARE, for example, does NOT cover either, and they are considered out-of-pocket expenses.) A referral is not a guarantee of payment.

(2) Treatment of eye diseases, either upon initial presentation or otherwise following the initial comprehensive eye exam, is a separate billable service. While treatment of eye diseases is not covered by vision insurances, it is usually covered by primary health insurances, including MEDICARE. If you have both types of insurance plans, it may be necessary for us to bill some services to one plan and other services to the other plan. We will follow a procedure called coordination of benefits to do this properly, in order to minimize your out-of-pocket expense.

(3) Contact lens fittings are a separate billable service from comprehensive eye exams (although they may be rendered on the same day), and a comprehensive eye exam within one year is an obligatory prerequisite for contact lens fittings. They may or may not be covered by your vision insurance and usually are not covered by your primary health insurance, including MEDICARE. Any subsequent follow-ups to refine the contact lens prescription are included at no charge for 90 days, or up to five follow-up visits, unless otherwise stated at the time of examination. I understand that professional fees collected for services rendered during a contact lens fitting (even if unsuccessful) are non-refundable.

(4) I hereby authorize my insurance company, including Medicare if I am a Medicare Beneficiary, to make payments to Insight Vision Care for medical services or items rendered to me or my dependent by Insight Vision Care. Should my insurance carrier deny Insight Vision Care payment I understand I am responsible for the charges. I authorize Insight Vision Care to release any and all of my records to my insurer, or any other third party payer, legally responsible for the payment of medical expenses. I certify that the information provided or to be provided by me is correct and complete to the best of my knowledge. It is my responsibility to update any and all personal, insurance and health information.

Insurance Waiver

Insight Vision Care will be happy to file your claim on your behalf. However any benefits quoted by us or relayed from your insurance carrier(s) are only an estimation of benefits, not a guarantee of coverage. A final determination cannot be made until a claim is processed by your insurance carrier(s).While we are willing to check for you, knowing your insurance benefits and restrictions are ultimately your responsibility. If your insurance company or policy requires a referral or prior authorization it is your responsibility to make sure that is obtained before services are provided. If services provided are not covered by your plan or are not a contractual obligation with that carrier, the bill will remain your responsibility.

Vision Insurance v.s Medical Insurance

We often have patients that have patients that have both vision and medical insurance. They are very different in terms of services they cover and it is important for our patients to understand those difference. Vision coverage is mainly designed to determine a prescription for glasses and is not equipped to deal with complex medical conditions and/or diagnoses and does not include a detailed examination of the retina. When a medical condition is present (such as high blood pressure, diabetes or eye disease) it is necessary to file the visit with your major medical carrier and the co-pays for that insurance will apply as well as any non covered services. Our office does not make these rules and they are defined by insurance carriers themselves. There is no way to know prior to the examination which type of insurance our office will have to file for you. We make every effort to be on every major carrier for your convenience and we will file those claims for you. In the event that we do not take your insurance we will provide you with an itemized receipt so that you may file with your carrier for reimbursement . If you have any questions please let us know.


7731 Flying Cloud Dr
Eden Prairie, MN 55344

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.

The most common reason we use or disclose your health care information is for treatment, payment or health care operations. We may use your health information inside our office for these purposes without any special permission. If we need to discuss your health information outside of our office for these reasons, we will ask you for special written permission.

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 care 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:
“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.

In some limited situations, the law allows and requires us to use or disclose you health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all.
  • 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 for 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;

  • For judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;

  • 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;

  • 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;

  • For health related research;

  • To prevent a serious threat to health or safety;

  • For specialized government functions, such as for the protection of the president or highest ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;

  • For de-indentified information;

  • Relating to worker's compensation programs;

  • 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; for example 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 with your family or friends who are bringing you to and from the office.


    We may call to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatment or services available at our office that might help you. Unless you tell us otherwise, we reserve the right to mail you an appointment reminder, and/or leave a reminder message on your phone if you are not home.


    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 for, 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 anytime unless we have already acted in reliance upon it. Revocation must be in writing. Send them to


    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 you want. To ask for a restriction, send a written request to Dr. Hasan.

  • 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

  • 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 60 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. If you want to review or get photocopies of your health information, send a written request to

  • Ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information generally within 60 days from when you ask for it. We will send you the corrected information to person 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 you health information. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to

  • Get a list of the disclosure 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. If you want a list, send a written request to

  • 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 .


    By law, we must abide by the terms of this Notice 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 website.


    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 If you prefer, you can discuss this in person or by phone.


    If you want more information about our privacy practices, call or visit Insight Vision Care at the address or phone number shown at the beginning of this Notice. By signing, I certify that I have been offered and reviewed Insight Vision Care’s Notice of Privacy Practices and all of my questions have been answered to my satisfaction in language that I can understand.


    Retinal Digital Eye Imaging Technology

    We are proud to offer our Digital Retinal Imaging, which will provide you and your family a highly advanced technology available in eye disease detection. This digital imaging allows us to thoroughly evaluate your internal eye health.

    Our Doctor is concerned about retinal diseases such as macular degeneration, glaucoma, retinal detachments, and diabetic retinopathy; all which can lead to partial loss of vision or blindness. Additionally, systemic diseases such as diabetes and high blood pressure can be detected with a retinal examination. Eye exams with retinal evaluations can help you safeguard both your eyesight and general health.

    Retinal Imaging Provides:

  • The ability to show you your retinal images today, during your exam.

  • An In-Depth 3D view of your retinal layers (where diseases can start).

  • A permanent record for your medical records, which gives your doctor a comparison for diagnosing and tracking retinal eye disease annually.

  • Retinal Imaging is:
  • Fast, easy, and comfortable.

  • Patient Friendly.

  • Eliminates the need to be dilated, in most cases.

  • Important Our doctor is committed to providing you and your family with the highest standards of eye care available. This is not covered by insurance and there is a $40.00 fee for this procedure.
    *Please inform office staff “I elect to have a Digital Retinal Image of my retina.” OR
    *Please inform office staff “I do not want a Retinal Image, I am willing to be dilated.”

    Patient Correspondence

    I am giving consent for Insight Vision Care to correspond with me over email.

    Social Media

    I may be asked if I am willing to have my photo posted on the social media pages for Insight Vision Care. I am signing that I have given verbal consent to allow my photo to be taken and posted.


    By signing below, I certify that I have been offered and reviewed Insight Vision Care's Assignment of Medical Benefits, Insurance Waiver, Notice of Privacy Practices, and Retinal Digital Photos Form and that all of my questions have been answered to my satisfaction in language that I can understand.

    Patient Signature: