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


Title First Last MI Suffix Nickname
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?
Title First Last MI Suffix
Address:
City: State: Zip Code:
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:
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!

History

Last Exam Date Pharmacy
Primary Care Provider Referring Provider
Accompanied by


Reason for visit


Chief Complaint


Medications Surgical History


Past Medical History Family History
Allergies


Social History

Occupation Lives with
Smoking Status Alcohol


Review of Systems

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

Submit Form / Signatures



Thank you for scheduling with us at Insight Vision Care. Please review and sign the document.

Assignment Of Medical Benefits

(1) 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.

(2) 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. I understand that professional fees collected for services rendered during a contact lens fitting (even if unsuccessful) are non-refundable.

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.

Credit Card on File Agreement

Insight Vision Care may require patients to keep a credit card or debit card on file to pay any balance due after insurance has made payment to us. This card will be used only to charge the balance due on the patient's account (including copayments, co-insurance amounts, deductibles). Your credit card information will be obtained and kept securely in our HIPAA compliant electronic system. Any balance owed will be applied to the card on file after 2 monthly statements have been sent without payment from the patient. By signing below, I authorize Insight Vision Care to keep my signature and my credit card information securely on-file. I authorize Insight Vision Care to charge my credit card for any outstanding balances when due and certify that I am an authorized user of this credit card and will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form. Should I wish to revoke this authorization at any time, I agree to send email/written notice to the office.

Appointment reminders:

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 orservices available at our office that might help you. Unless you tell us otherwise, we reserve the right to send you appointment reminders.

Patient Correspondence

I am giving consent for Insight Vision Care to correspond with me over email. Consent can be revoked by notifying us at any time.

Social Media

I may be asked if I am willing to have my (or my child's) photo posted on the social media pages for Insight Vision Care. I am signing that I have given my consent to allow a photo to be taken and posted. Consent can be revoked by notifying us at any time.

Notice of HIPAA Privacy Practice

 Click here to view our HIPAA Privacy policy https://insightvisionmn.com/hipaa/


By signing below, I certify that I have reviewed and agree to Insight Vision Care's Assignment of Medical Benefits, Insurance Waiver, and other office policies, including the Notice of Privacy Practices, and that all of my questions have been answered to my satisfaction in language that I can understand.

Patient / Guardian Signature::