Online Patient Forms



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COVID-19

COVID-19 Update from Tatum Eye Care


--Please wear a mask to enter our Office--

We continue to adjust our protocols in order to protect our patients and staff from the community spread of COVID-19.
In accordance with the Maricopa County Department of Public Health, we are implementing the following actions below:

**Anyone entering our office (regardless of symptoms) is expected to wear a mask or face covering. Bandanas or handmade masks are acceptable.

All staff members working with patients will consistently wear facial masks as well. This will help to protect against asymptomatic or pre-symptomatic transmission of the virus.

**Upon entering our office, we ask that each patient stop after entering the front door and a staff member will check your temperature with a non-contact thermometer. Anyone with a fever will need to reschedule after seeing their family physician.

**We continue to actively screen our patients, staff and doctors asking that no one enter our facility if they have had exposure to someone diagnosed with COVID-19 or have any new onset cough or fever.

--We appreciate everyone's cooperation & flexibility as we do our part to slow the spread of COVID-19. Social distancing in the office has worked well. We stay committed to following the guidance of the World Health Organization, Centers for Disease Control as well as the public health officials who are closely tracking data specific to Arizona.

Please Note: Our office will begin scheduling patients in May with guidance from the CDC and the Arizona State Board of Optometry. We will be limiting the number of patients allowed in our office at one time. Therefore, please bear with us as we try to accommodate your needs. Your safety and health is our utmost concern as our office reopens to provide you with ocular examinations, glasses and contact lenses. Please call the office with any questions.

Tatum Eye Care
480-889-6044


Please be aware of changes we have implemented at the office in response to Covid-19.

We are now requiring patients to fill out paperwork at home through our new online portal.

Patients are asked to bring in their own masks or face covering.

Patients exhibiting any signs of upper respiratory illness will be asked to reschedule.

We will be reducing the number of exams that we see to minimize the number of patients in the office at one time.

When the patient arrives, they will call from the parking lot and the staff will invite them in or come out and get them shortly.

We will be limiting the number of patients in the optical dispensary.

When trying on frames, discarded frames will be put aside and sterilized.

Contact lens orders will be sent directly to patient.

We will continue to do curbside pickup and adjustment of glasses.


Patient Siganture: Date:

Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Patient Accommodations:
Cell Phone: Preferred Contact Method:
Last 4 Of SSN Email
Birthday (mm/dd/yyyy) Occupation
Sex
Employer / School Name
Guardian



Vision Primary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
City: State: Zip:
Birthday:
Last 4 Of SSN:
Employer/School:

Vision Secondary

Insurance Information
Insurance Name:
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 Primary

Insurance Information
Insurance Name:
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 Secondary

Insurance Information
Insurance Name:
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:

Ocular 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:

Eye History

Do you currently or have you ever had these ocular conditions?:
Please List Any Eye Medications?:
Have you had any eye surgeries? Please describe:
Last Eye Exam: By Doctor:

Primary Vision Correction:

Contact Lens Wearers (Only fill out if you are new to the practice)
Brand Of Contacts: Cleaning Solution: Replacement Schedule:
Wear Time:

Family Eye History

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


Medical History


Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Patient Medical History
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: Last A1C: When:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Family Medical History

Unknown family 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:

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:
Marital Status Employment Status


Review of Systems


Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Musculoskeletal:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genitourinary:
Immune:





Retinal Imaging

Retinal Imaging

Our doctors now recommend that all patients elect to have their retinas imaged with the Optos Retinal Camera.

Taking the Optomap image takes less than half a second and nothing touches your eye at any time. The Optos camera is capable of capturing up to 80% of your retina in one panoramic scan.

The Optos camera helps our doctors diagnose eye disease such as glaucoma, macular degeneration, diabetic retinopathy, retinal melanoma and peripheral abnormalities such as holes, tears and detachments. The picture will remain in your health record to help detect any future changes.

Unlike pupil dilation, the Optos scan does not cause blurry vision, light sensitivity or affect driving.



There is a $20.00 charge for this digital photo documentation and is not generally covered by your insurance.

Yes, I would like this procedure performed.
No, I do not want this procedure performed.

Signature: Date:

HIPAA Policy



NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.


OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. In the event we make a material change in our privacy practices, we will change this Notice and provide it to you. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to an optician, ophthalmologist or other healthcare provider providing treatment to you for: a) the provision, coordination, or management of health care and related services by health care providers; (b) consultation between health care providers relating to a patient; (c) the referral of a patient for health care from one health care provider to another; or (d) recall information.

Payment: We may use and disclose your health information to obtain payment for services we provide to you. This may include: (a) billing and collection activities and related data processing; (b) actions by a health plan or insurer to obtain premiums or to determine or fulfill its responsibilities for coverage and provision of benefits under its health plan or insurance agreement, determinations of eligibility or coverage, adjudication or subrogation of health benefit claims; (c) medical necessity and appropriateness of care reviews, utilization review activities; and (d) disclosure to consumer reporting agencies of information relating to collection of premiums or reimbursement.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include things such as quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

Marketing Health Products or Services: We will not use your health information for marketing communications without your prior written authorization. We may provide you with information regarding products or services that we offer related to your health care needs. We will never sell your health information without your prior authorization.

To You, Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so or, if you are not able to agree, if it is necessary in our professional judgment.

Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Required by Law: We may use or disclose your health information when we are required to do so by law, including judicial and administrative proceedings.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders and Treatment Alternatives: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters) or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

PATIENT RIGHTS

Access: You have the right to review or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations, where you have provided an authorization and certain other activities, for the last 6 years, but not for disclosure made prior to April14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request in writing that we communicate with you about your health information by alternative means or to alternative locations. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.

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

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact: Office Manager
Telephone: 480-889-6044 Fax: 480-889-6047
E-mail: HIPPA@TatumEyecare.com
Address: 16429 N. Tatum Blvd., Phoenix, AZ 85032