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Demographics

Patient Information
TitleFirstLastMISuffixNickname
Address: Apt/Suite #:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN (Last 4) Email
Birthday Occupation
Sex Employment Status
Marital Status Employer/School Name
Primary Eye Doctor Misc/Guardian




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:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

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:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision

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:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Other

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:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Chief Complaint



What is the main reason for your visit today? (examples: I need a diabetic eye exam, my eyes are dry, my vision is blurry with glasses or contacts, etc):
Please elaborate on any eye related concerns you'd like to bring up at your visit:

How do you use your eye most of the day? What are your main visual tasks?:

PATIENT OCULAR HISTORY

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

Previous Injuries, Infections, Surgeries, Diseases:

Eye Meds:
Last Eye Exam:

FAMILY OCULAR HISTORY

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Glaucoma: Cataracts: Macular Degen:
Retinal Detach: Crossed / Lazy: Other:

Primary Vision Correction:


Medical History


Please complete this as thoroughly as possible - thank you!

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PRIMARY CARE PHYSCIAN: PCP Phone #: PCP FAX #:

SYSTEMIC MEDS:

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Do you have diabetes? Type: A1C: Blood Sugar: Controlled?

Additional Meds:
Over The Counter Meds:
Vitamins:
Drug Allergies:

Height:Ft.In.           Weight:Lbs.

PAST PATIENT MEDICAL HISTORY (HAs, Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Dz, Seizures, Thyroid):

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


Injuries, Surgeries, Hospitalization

If applicable are you pregnant or nursing:

Notes:

IMMEDIATE FAMILY MEDICAL HISTORY (Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other):

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


SOCIAL HISTORY

Occupation: Hobbies:

Smoking Status
Alcohol:
Recreational Drugs:
STD:


Review of Systems


Please type in relevant information with approximate dates. Thank you!

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

GENERAL: ( Fever, weight loss, weight gain, fatigue)
EAR, NOSE, THROAT: (Allergies, Sinus, Cough, Dry Mouth / Throat)
CARDIOVASCULAR: ( High BP, Heart Surgery, Vascular Disease)
RESPIRATORY: (Asthma, Bronchitis, Emphysema, COPD)
GENITAL, KIDNEY, BLADDER: ( Kidney Stones, Frequent Urination, Impotence)
MUSCLES, BONES, JOINTS: (Athritis, Joint Pains, Head or Neck Injury)
SKIN: (growths, rashes, acne)
NEUROLOGICAL: ( Headaches, migraines, seizures)
PSYCHIATRIC: (Depression, Anxiety, Insomnia)
ENDORCRINE: (Thyroid, Diabetes)
BLOOD/LYMPH: (Anemia, cholesterol, bleeding problems)
ALLERGIC / IMMUNOLOGIC: (Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus)
GASTROINTESTINAL: (Diarrhea, Constipation, Ulcer, Reflux)


Policies, Consent, and Submit Data


Please read the following and check, sign and date below.
Thank you!

FINANCIAL POLICY FOR HORIZON EYE CARE & OPTICAL

Welcome and thank you for choosing Horizon Eye Care & Optical for your eye and vision care.
We are committed to providing you with quality vision and eye care. Our professional fees have been determined through careful consideration, and we believe these fees are reasonable and competitive. We are pleased to discuss with you any questions you may have concerning your bill. Providing G.R.E.A.T. care is our primary concern.
Regarding Insurance
Vision, Medical and Private Insurance: Horizon Eye Care & Optical (HECO) will file claims directly with your insurance plan for services where covered benefits have been verified. Please note, insurance verification does not guarantee your insurance will pay for all of our services. Medical insurance will usually not cover routine vision services (examples include vision exams, contact lens evaluations, eye glasses, contact lenses). Likewise, vision insurance will not cover medical diagnoses (examples include dry eyes, eye allergies, infections, cataracts, other eye conditions). Payment of co-insurance, co-pays, deductibles or fees for non-covered services, or extras, when applicable, is required to be paid at the time of service.
Contracted Managed Care Plans (HMO, PPO, EPO, POS, etc.) Every time you make an appointment with HECO for medical eye care, deemed as non-routine vision services, it is your responsibility to make sure our optometrists are currently under contract with your plan and you have obtained any necessary referrals when needed. Verification of your plan benefits/coverage is required before you are seen. Often this verification requires us to share the reason for your visit with a managed care plan. Payment of co-insurance, co-pays, deductibles or fees for non-covered services, or extras, when applicable, is required to be paid at the time of service.
We allow 30 days from the date a claim was filed by our office for any vision or medical insurance company to pay. If the insurance has not paid within this time frame, you may become responsible for the entire balance. We will not become involved in disputes between you and your insurance company regarding deductible, non-covered services, co-insurance, co-payments, coordination of benefits or pre-existing conditions, other than to supply factual information relating to your treatment. You are responsible for the timely payment of your account.
Medicare: HECO accepts assignment of Medicare benefits. However, you may be asked to sign a waiver to acknowledge your understanding of your responsibility to pay for services not covered by Medicare, such as refraction for the determination of your vision prescription.
Minors: The parent(s) or guardian(s) of a minor is responsible for providing current insurance information and/or payment in full for services provided. Unaccompanied minors must have authorization for medical treatment signed by a parent or guardian and are responsible for current insurance information for self and/or payment in full for services provided. Minors will not be allowed to purchase glasses or contact lenses without written permission as well as payment in full for products from the parent or guardian.
Method of Payment: For your convenience, HECO will be happy to accept your payment by cash, check, or credit card. A $25 fee will be assessed to your account for all returned checks.
Returns and Cancellations: Once purchased, all sales are final and no refunds are given for eyeglasses or contact lenses. If orders are cancelled before your eyeglasses are made, we will refund in full minus a 3% credit card transaction fee.
Appointment Cancellation Fee: For appointments, there is a $40 no show fee or cancellation fee if not notified 24 hours prior. We understand emergencies occur and accommodate those without cancellation fees. This policy is effective for all current and future appointments.
I have read and understand the above terms and conditions and will verify so by giving my signature.

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. PLEASE REVIEW IT CAREFULLY.


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.

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS


The most common reason why we use or disclose your health information is for treatment, payment or health care operations. 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 or verifying the prescription if verification is requested by an outside laboratory, pharmacy, or retail establishment; 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 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" 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. We routinely use your health information inside our office for these purposes
without any special permission. If we need to disclose your health information outside of our office for these reasons, we usually will not ask you for special written permission.
We will ask for special written permission when the use of your health information does not fall within the guidelines described above, or when they do, we feel there are mitigating circumstances that make the receipt of your permission advisable.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION


In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; 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 drug 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;
- 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;
- disclosure 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;
- uses or disclosures for health related research;
- uses and disclosures to prevent a serious threat to health or safety;
- 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 and health of members of the Foreign Service;
- disclosures of de-identified information;
- disclosures relating to worker's compensation programs;
- disclosures of a "limited data set" for research, public health, or health care operations;
- 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 about your care with your family or friends who are helping you with your eye and/or health care.

APPOINTMENT REMINDERS


We may call, write or text 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 treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a post card, and/or leave you a reminder message on your home or office answering machine/voicemail or with someone who answers your phone if you are not at home or work.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION


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 that you want. To ask for a restriction, send a written request to the office address shown at the beginning of this Notice.
- 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 Email to your personal Email 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 the office address shown at the beginning of this Notice.
- 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 sixty days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your requests, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30-day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office address shown at the beginning of this Notice.
- ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons 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 your health information. By law, we can have one 30-day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request to the office address shown at the beginning of this Notice.
- get a list of the disclosures that 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, but by law we can have one 30-day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office address shown at the beginning of this Notice.
- 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 the office address shown at the beginning of this Notice.

OUR NOTICE OF PRIVACY PRACTICES


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

COMPLAINTS


If you think that we have not properly respected the privacy of your health information, you are free to complain to U.S, Department of Health and Human Services or the US 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 request to the office address shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.

FOR MORE INFORMATION


If you want more information about our privacy practices, call or visit our office at the address indicated.

ACKNOWLEDGEMENT OF RECEIPT


I acknowledge that upon request I have received a copy of the Horizon Eye Care & Optical Notice of Privacy Practices.


EYE HEALTH SCREENING



In order to better evaluate your eye health, our doctors require retinal imaging as part of your examination.

OPTOMAP RETINAL IMAGING:


The Optomap gives an ultra-wide field image of the back of your eyes to supplement your eye health exam. Taking the image is painless, doesn't involve drops and only takes several seconds. Our doctors will review the results with you during your examination.

The $39 copay is in addition to your examination copay.

Optomap will be part of your eye health exam unless refused at time of exam


ADVANCED COMPREHENSIVE IMAGING:



Our comprehensive imaging is optional and INCLUDES the Optomap and O.C.T, which gives a series high resolution scans of the back of your eyes. It lets our doctors detect and monitor glaucoma, macular degeneration, and complications from diabetes or high blood pressure.

You should consider the Advanced Comprehensive Imaging if:
- you have diabetes or high blood pressure
- you have a family history of glaucoma, macular degeneration or other eye diseases
- you are older than 40

The imaging process is quick, painless and does not involve drops. There are no side effects and this comprehensive technology is available for $80. If ordered by our doctors to follow active ocular disease, the imaging will be billed to your health insurance.

O.C.T of an eye affected by diabetes:



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