Patient information

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Type None if you Decline^

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Billing information

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Primary Vision Insurance


If not using insurance, please type “None” in the Insurance name, ID and Policy group boxes

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Primary Medical Insurance

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Medical History

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Eye History

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Note: Most insurance plans either: Do not cover Contact Lens Evaluation or Require a copay.

Contact Lens Wearers only:

Medical History:

Do you have any of these medical conditions?

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Family Medical History

Does anyone in your family have any of these medical conditions?


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Family Eye History

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


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Review Of Systems














Social History


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Notice of Privacy, Policies and Agreement


Patient acknowledges that


It is the patient's responsibility to check if we are out-of-network with their insurance plan prior to their visit.
It is the patient's responsibility to file insurance claims if we are not contracted with your insurance company.

I understand that all charges for professional services rendered are my responsibility. I understand this office, if contracted with my insurance company, will file a claim to my insurance company on my behalf.

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I authorize payment of benefits to Eric Verret OD, Inc.

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Your doctor will accept the fee approved by your insurance as payment in full for any covered services. The patient will be responsible for any amount approved but not paid by the insurance as well as the full amount for all non-covered services.

I agree to assume responsibility for co-payments and deductibles as specified by my insurance and for the charges of any non-covered services.

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NOTICE OF PRIVACY PRACTICES


THIS NOTICE OF PRIVACY PRACTICES ("NOTICE") DESCRIBES HOW WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION AND HOW YOU CAN GET ACCESS TO SUCH INFORMATION. PLEASE READ CAREFULLY.

Your "health information", for purposes of this Notice, is generally any information that identifies you and is created, received, maintained or transmitted by us in the course of providing health care items or services to you (referred to as “health information in this Notice). We are required by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and other applicable laws to maintain the privacy of your health information to provide individuals with this Notice of our legal duties and privacy practices with respect to such information, and to abide by the terms of this Notice. We are also required by law to notify affected individuals following a breach of their unsecured health information.

USES AND DISCLOSURES OF INFORMATION WITHOUT YOUR AUTHORIZATION

The most common reasons why we use or disclose your health information are for treatment, payment or health care operations. Examples of how we use or disclose your health 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 information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payments purposes are asking you about your health or vision care plan, or other sources of payments, preparing and sending bills or claims; and collection unpaid amounts (either ourselves or through a collection agency or attorney). "Health care operations” means those administrative and managerial functions that we must carry out in order to run our office. Examples of how we use or disclose your health information for health care operation 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.

OTHER DISCLOSURES AND USES WE MAY MAKE WITHOUT YOUR AUTHORIZATION OR CONSENT

In some limited situations, the law allows or requires us to use or disclose your health information without your consent or authorization. Not all of these situations will apply to you; some may never come up at our office at all. Such uses or disclosures are:

•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 from 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 my Medicare or Medicaid, or for investigation of possible violations of health care laws;
•Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
•Disclosures 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;
•Disclosures to a medical examiner to identify a dead person or to determine the cause of death or in funeral directors to aid in burial or to organizations that handle organ or tissue donations;
•Uses or disclosures for health related research;
•Uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials for lawful national intelligence activities; for military purposes; or for the evaluation & health of members of the foreign service;
•Disclosures relating to worker's compensation programs;
•Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
•Disclosures to “business associates” and their subcontractors who perform health care operations for us and who commit to respect the privacy of your health information in acceptance with HIPPA;

Unless you object, we will also share relevant information about your care with any of your personal representatives who are helping you with your eye care. Upon your death, we may disclose to your family members or to other persons who were involved in your care or payment for health care prior to your death (such as your personal representative) health information relevant to their involvement in your care unless doing so is inconsistent with your preferences as expressed to us prior to your death.

SPECIFIC USES AND DISCLOSURES OF INFORMATION REQUIRING YOUR AUTHORIZATION

The following are some specific uses and disclosures we may not make of your health information without your authorization:
Marketing activities. We must obtain your authorization prior to using or disclosing any of your health information for marketing purposes unless such marketing communication takes the form of face-to-face communications we may make with individuals or promotional gifts of nominal value we may provide. If such marketing involves financial payment to us from a third party, your authorization must also include consent to such payment.
Sale of health information. We do not currently sell or plan to sell your health information & we must seek your authorization prior to doing so.
Psychotherapy notes. Although we do not create or maintain psychotherapy notes on our patients, we are required to notify you that we must obtain your authorization prior to using or disclosing any such notes.

YOUR RIGHTS TO PROVIDE AN AUTHORIZATION FOR OTHER USES AND DISCLOSURES

•Other uses and disclosures of your health information that are not described in this Notice will be made only with your written authorization.
•You may give us written authorization permitting us to use your health information or to disclose it to anyone for any purpose.
•We will obtain your written authorization for uses and disclosures of your health information that are not identified in this Notice or are not otherwise permitted by applicable law.
•We must agree to your request to restrict disclosures of your health information to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and such information pertains solely to a health care item or service for which you have paid in full (or for which another person other than the health plan has paid in full on your behalf).

Any authorization you provide to us regarding the use and disclosure of your health information may be revoked by you in writing at any time. After you revoke your authorization, we will no longer use or disclose your health information for the reasons described in the authorization. However, we are unable to restrict any disclosures that we may have already made with your authorization. We may also be required to disclose health information as necessary for purposes of payment for services received by you prior to the date you revoked your authorization.

YOUR INDIVIDUAL RIGHTS

You have many rights concerning the confidentiality of your health information. You have the right:
To request restrictions on the health information we may use and disclose for treatment, payment and health care operations. We are not required to agree to these requests. To request restrictions, please send a written request to us at the address below.
To receive confidential communications of health information about you in any manner other than described in our authorization request form. You must make such requests in writing to the address below. However, we reserve the right to determine if we will be able to continue your treatment under such restrictive authorization.
To inspect or copy your health information. You must make such requests in writing to the address below. If you request a copy of your health information, we may charge you a fee for the cost of copying, mailing or other supplies. In certain circumstances, we may deny your request to inspect or copy your health information, subject to applicable laws.
To amend health information. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, you must write to us at the address below. You must also give us a reason to support your request. We may deny your request to amend your health information if it is not in writing or does not give us a reason to support your request. We may also your request if the health information:

 • Was not created by us, unless the person that created the information is no longer available to make the amendment;
 • Is not part of the health information kept by or for us;
 • Is not part of the information you would be permitted to inspect or copy,
 • Is accurate and complete.

To receive an accounting of disclosures of your health information. You must make such requests in writing to the address below. Not all health information is subject to this request. Your request must state a time period for the information you would like to receive, no longer than 6 years prior to the date of your request. Your request must state how you would like to receive the report (paper or electronically).
To designate another party to receive your health information. If your request for access to your health information directs us to transmit a copy of the health information directly to another person, the request must be made by you in writing to the address below and must clearly identify the designated recipient and where to send the copy of the health information.

Changes to this Notice: We reserve the right to change our privacy practices and to apply the revised practices to health information about you that we already have. Any revision to our privacy practices will be described in a revised Notice that will be posted prominently in our office. Copies of this Notice are also available upon request at our reception area. Notice Revised and Effective: August 15, 2022.

Download our Notice of Privacy

I hereby acknowledge that I received a copy of this medical practice's Notice of Privacy Practices and that I will be offered a copy of any amended Notice of Privacy Practice at each appointment.

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RELEASE OF MEDICAL INFORMATION

I authorize release of my medical information to the following persons.


PHYSICIAN PATIENT ARBITRATION AGREEMENT


Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Bothparties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated: It is the Intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term "patient" herein shall mean both the mother and the mother's expected child or children.
All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician's partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action In any court by the physician or patient to collect or contest any medical fee shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any malpractice claim, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party's pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not Including counsel fees or witness fees, or other expenses Incurred by a party for such party's own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting In the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law.

Article 4: General Provisions: All claims based upon the same Incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof Is received, the claim. If asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant faills to pursue the arbitration claim In accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (induding, but not limited to, emergency treatment) patient should check I agree below:

Effective as of the date of first medical services.

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If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

Patient Consent Form - Escondido Eyecare
Please read carefully and check the designated checkbox to confirm that you had read and understood each section of this consent form.

Coverage Terms
Your insurance policy is an agreement between you and your insurance company. It is your responsibility and not that of Dr. Verret's office to know your policy terms and conditions. We try to verify your eligibility and benefits as a courtesy. However, we would know the exact details of payments only after claims are processed. check I agree below.

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Authorization
If your insurance company requires authorization from your Primary Care Provider, it is your responsibility to obtain the relevant authorization before your visit. Otherwise, the cost of your visit will be your responsibility.

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Insurance Company Disputes
The negotiation of payments that are due to your service providers or the settling of any disputes that may arise between you and your insurance company is entirely your responsibility.

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Payment/Outstanding Balances
All payments and copays are before receiving the service. Any outstanding balances should be settled before the visit of the physician. All your account balances have to be current. We can work with you on convenient payment plans, should you require so.

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Collection Policy
You will be responsible for interest and penalties if payments are not settled upon receiving the monthly billing statement. Any unpaid debt to Dr. Verret's office is handled by a third party collection company. If your account is sent to collections, you are responsible for settling any attorney fees, interest, or penalties applicable by law. You may even be discharged from the practice if your account is sent to collections.

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Copy of Medical Records or Disability Paperwork
If you need any medical records from us, please send a written request to authorize the release of such records. We charge $25 upfront for copies of medical records or disability paperwork. Please note that processing takes 1 - 2 weeks from the date of receipt of such requests.

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Late to Appointments
If you are more than 15 minutes late for your appointment, please understand that you may have to reschedule your appointment.

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Cash Agreement
I acknowledge that I am responsible for the cost of my visit at the Escondido Eyecare and/or any testing done if my insurance information is not provided at the time of visit or insurance information is inaccurate, inactive or ineligible. If you have any concerns please do not hesitate to contact the office at (760) 747-7979.

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Consent to Video Recording
I understand that Escondido Eyecare has video surveillance in its office spaces for quality assurance purposes. I consent to video recording while I am at Escondido Eyecare's premises.

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Consent to Retinal Scan or Dilation
As part of your eye exam, your eye doctor can evaluate your retina in 3 different ways:

1 DILATION
We can use dilating drops to enlarge your pupils ("dilation"). This allows for a complete evaluation of your central and peripheral retina. Dilation involves instilling eye drops for the purpose of enlarging the pupils of the eyes to better check the health of the inside of the eyes. The pupils are simply an opening to the inside of the eye. Looking through an undilated pupil is similar to looking into a room through a keyhole in the door; the doctor may see only about 20% of what is inside. However, looking through a dilated pupil is like looking into a room through an open door; the doctor gets a complete view of the inside of the eye. Dilation allows the doctor a better view of the peripheral retina and find diseases that would have been missed otherwise. However, no photos are taken.
Patients with high prescriptions, past retinal problems (i.e. retinal detachment/tears), sudden cloudiness of vision, especially in one eye, "curtain or veillike" obstruction of vision, a sudden onset of many "floaters" or flashing lights off to the side of your vision, diabetes, and high blood pressure are STRONGLY advised to have their eyes dilated yearly. In addition, patients with a family history of glaucoma, macular degeneration or blindness should also be dilated annually.
Side Effects
A wait time of 30 minutes is required to allow the drops to take effect before the doctor can examine your eyes. Some blurring of vision and glare because of enlarged pupils for about 3 to 6 hours. You should not operate heavy equipment or drive an automobile. Difficulty with near reading for 2 to 3 hours. The focusing ability is impaired and may cause a slight headache if you try to read and may prevent you to work during this time. Sensitivity to light. Burning upon instillation of drops. Induced ocular hypertension (high pressure inside the eyes). Rare cases have been reported in which redness and sharp pain are experienced.


2 OPTOMAP WITH THE OPTOS
We can evaluate your retina by taking a retinal scan (picture of the retina). With this option, we will be able to keep photos on file, which makes it very easy to compare from one year to the next.
Side effects
NONE


3 BASIC RETINAL CAMERA
The doctor will only be able to see the central retina and many eye and/or systemic diseases can be missed.
Side effects
NONE


In order to provide the most comprehensive exam possible we request that all of our patients have a dilated eye exam or have a retinal scan performed.

REFUSAL TO HAVE YOUR PUPILS DILATED OR HAVE A RETINAL SCAN PERFORMED MAY CAUSE YOUR DOCTOR TO BE UNABLE TO DETECT CERTAIN DISEASES.

I understand that dilation of my pupils or a retinal scan is a very important diagnostic tool that aids the doctor in determining my state of health. I understand that by refusing dilation or retinal scan, I risk having a sight-threatening disorder or other disease left undiagnosed.

PLEASE CHOOSE ONE OF THE FOLLOWING:

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