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
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code:
Home Phone:
Work Phone:
Other Phone:
Alerts:
Cell Phone:
Preferred Contact Method:
Home Phone
Work Phone
Cell Phone
Other Phone
Text Message
Email
SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Widowed
Employer / School Name
Misc/Guardian
Billing Information
Is The Billing Address Different?
Yes
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code:
Home Phone:
Work Phone:
Primary Medical Insurance
Insurance Information
Insurance Name:
None
Aetna
Aetna Medicare
BCBS
Cigna
EyeMed
Humana
Humana Medicare Network PFFS
Humana Medicare PPO
Medicare
Tricare OON
United Health Care
VSP
Insurance Plan:
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:
Primary Vision Insurance
Insurance Information
Insurance Name:
None
Aetna
Aetna Medicare
BCBS
Cigna
EyeMed
Humana
Humana Medicare Network PFFS
Humana Medicare PPO
Medicare
Tricare OON
United Health Care
VSP
Insurance Plan:
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:
Ocular History
Reason for Visit:
Primary Reason:
History of Present Illness:
Do you currently have any of these symptoms?:
None
Itching
Burning, Stinging
Red
Floaters
Flashes Of Light
Eye Injuries
Eye Surgery
Amblyopia
Strabismus
Cataracts
Glaucoma
Retinal Disorders
Other
Have you had any eye surgeries? Please describe:
Last Eye Exam:
By Doctor:
Please include any additional pertinent ocular history:
Medications
Medications:
No Meds Used
Drug Allergies:
No Known Drug Allergies
Primary Care Physician:
Last Visit:
1 week
1 month
3 months
6 months
1 year
2 years
greater than 3 years
Other
Primary Care Physician Contact Tel and Fax:
Preferred Pharmacy:
Pharmacy Tel and Fax:
Family Ocular History
Please include any pertinent family ocular history:
Medical History
Please include any pertinent systemic medical history:
Family Medical History
Please include any pertinent family medical history:
Acknowledgment of Notice of Privacy Practices
Click here to read the full Privacy Policy
The law requires that Innovista Eye make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that:
I was given the opportunity to read, have read or had explained to me Innovista Eye's Notice of Privacy Practice prior to any services offered.
The Notice of Privacy Practice could not be read due to the emergent nature of the care and will be acquired when possible
I authorize Innovista Eye to release my personal health information to the following individuals:
I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.
Patient Signature:
Date:
If you are signing as a personal representative of the patient, please indicate your relationship. If you are signing for a minor, you attest that you have legal authority to make medical decisions for the minor
Representative Signature:
Relationship to Patient:
Financial Disclosure
I understand that
vision plans
(VSP, EyeMed, etc) are
NOT
medical insurances and therefore only cover
wellness
or
routine vision
services
I understand vision plans do
NOT
cover or contribute to chronic management or treatment of ocular disease, medical procedures, or specialized testing
I understand that
medical insurance
will be necessary to cover or contribute to medical diagnoses, management or treatment of ocular disease, or other medical procedures performed
I understand that in order to maximize my usage of benefits,
Innovista Eye
requires all patients to present
both
medical insurance and vision plan information at the time of scheduling
All professional services, material charges, and fees are due at the time services are rendered, unless other written arrangements are made in advance
Custom eyewear measurements performed by our trained opticians, including pupillary distance (PD), are included at no cost when purchasing eyewear through our office. We do provide this service for
$45.00
for eyewear purchased outside our office
Due to varying quality in materials, proprietary lens technology, and services obtained at other clinics and retail settings, all verification and rechecks of glasses prescriptions and/or eyewear measurements that have been purchased and/or manufactured outside of Innovista Eye will incur a
$45.00
charge for our professional time
Unpaid accounts exceeding
90 days
are subject to collection fees
Initials:
I hereby understand and fully agree with the above office policies, charges, and protocols.
There will be a service charge of
$30.00
on all returned checks
Missed appointments without a courtesy 24-hour notice will incur a charge of
$45.00
Refraction
testing is
NOT
a covered service by Medicare and other third-party medical carriers - this is a
$60.00
out-of-pocket service that is due at the time of comprehensive evaluations and/or when glasses prescriptions are given
Contact lens exams and services
start at $120.00 in addition to the exam fee
depending on the type, complexity, plan coverage, etc. This includes all necessary testing and imaging, as well as 60 days of no charge visits to finalize a prescription. Please notify us if you are interested in specific contact lens services for a more accurate estimate.
Digital Ocular Imaging
= $45.00
Similar to dental imaging, this is a comprehensive, digital, multi-image ocular scan that assess the optic nerve, retina, and other structures of the eye down to the micron scale to detect early disease
This test is part of our comprehensive eye exam to establish an ocular health baseline for ALL of our patients, and is part of our
standard of care
I understand this test cannot be unbundled as per our office policy and will be performed on all comprehensive exams
I understand that this is Non-Covered Service by any Vision Plan (VSP/Eyemed) and therefore is NOT included with "routine exam" copays
Routine dilation will be performed in
addition
to this test as per the discretion of the doctor for each individual case based on medical necessity
Your doctor will carefully review any findings or abnormalities during your exam
Initials:
I hereby understand and fully agree with the above office policies, charges, and protocols.
The undersigned will ultimately be responsible for any remaining balance after insurance coverage has been applied. I hereby understand and fully agree with the above office policies, charges, and protocols.
Patient Signature:
Date:
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