NW Vision Development Center Patient Registration Form

Directions for this form: After completing your information, click on the final tab to the right.
Then, when finished reading, click the 'Click Here to Submit Data' button at the top or bottom of the page.
After you click the button, the information will get securely uploaded into our record system.

Click here to return to the previous website.

Demographics

Title First Last MI Nickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone:
SSN Email Address
Date Of Birth Occupation
Sex Male Female
Employer or School Name
Parents Names?
Billing Information Is The Billing Address the Same?
Title First Last MI Suffix
Address

City State ZipCode
Home Phone:
Work Phone:

Primary Insurance

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

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:

Tertiary Insurance

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:

Patient History


What Is The Reason For Your Exam Today?


VISUAL SYMPTOM QUIZ

Please Check The Box To Indicate "Yes" To The Questions

Do you skip or have to reread words when reading?
Do you find it easier to close or cover one eye?
Do you commonly have to use your finger to guide your eyes when reading?
Do your eyes hurt or become tired?
When writing, do you reverse letters/numbers?
Do you get double vision or do the words "split apart" when reading?
Do your eyes itch?
Do your eyes get red?
Do your eyes feel dry?
Do you get floating spots in your vision
Do you get flashing lights in Your vision
Are you bothered by glare while driving?
Are you bothered by glare while using computers/phones/tablets?
Do you use the computer or tablet?

How many hour per day do you use a computer/tablet/phone?


What is your occupation?


Do you have any hobbies?


Are there activities you enjoy but are restricted to because of your vision?


Would you like to correct your vision without using glasses/contacts/surgery?



Personal Medical History

Please Put A Check In The Box If You Have (Or Have Had) Any Of The Following:

EYE RELATED CONDITIONS (SELF)

Lazy Eye
Turned Eye
Retinal Condition
Blindness
Glaucoma
Macular Degeneration
Cataracts
Eye Surgery

SYSTEMIC CONDITIONS (SELF)

Arthritis
Diabetes Type 1 Type 2
Cancer
High Cholesterol
Heart Disease
High Blood Pressure
Hypo / Hyper Thyroid
Migraines/Headaches
Skin (Acne/Cancer)
Gastrointestinal
Head Trauma
Concussion Stroke Whiplash
Kidney/Bladder
Neurological
Psychiatric
Respiratory/Breathing
Other (Describe)

If Female
Currently Pregnant

Current Medications/Vitamins/Supplements: (Please List)

Please List Any Social or Illicit Drugs (Alcohol, Tobacco, Marijuana etc.) Regularly Taken:

Please List Any Allergies:

Are There Any Other Medical Illnesses/Conditions?

When Was Your Last Eye Examination?

If Applicable, Who Was Your Last Eye Care Provider?
Who Is Your Primary Care Physician?

When Was Your Last Physical Exam?:


Family History

Please Check Any Family Related Conditions And Indicate Which Family Member In The Boxes Next To The Condition

EYE DISEASE/CONDTIONS (FAMILY)

Glaucoma
Macular Degeneration
Retinal Condition
Cataracts
Lazy eye
Turned eye
Blindness
Crossed Eyes
Eye surgery

SYSTEMIC DISEASE/CONDITIONS (FAMILY)

Diabetes
Cancer
High Cholesterol
Heart Disease
High Blood Pressure
Thyroid
Migraine/Headaches
Skin (acne,cancer)
Gastrointestinal
Kidney/Bladder
Neurological
Respiratory/Breathing Problems

For Children 12 And Under Only

THIS FORM SHOULD BE FILLED OUT FOR ALL CHILDREN 12 AND UNDER

DEVELOPMENTAL HISTORY

Is Your Child Adopted?


If yes, does the child know?


Age when adopted?


Full Term Pregnancy?


Were There Any Complications before, during or after delivery?


Was the child exposed in utero to:
Nicotene Alcohol Drugs

Did your child crawl?


When Did Your Child First Walk?

When Did Your Child First Speak Words?


When Did Your Child First Speak Sentences?


When Stressed Or Under Tension, is there any pattern of behavior, thumb-sucking, etc?


Has your child had occupational therapy?
Comments:

Has your child had physical therapy?
Comments:

Has your child had speech therapy?
Comments:

Has your child had academic help outside school (i.e. reading specialist)?
Comments:


SCHOOL HISTORY
Does Your Child Like School?


Has your child repeated a grade?


Which one?


Is Your Child's School Performance:


Have there been any school difficulties?


Which subjects are easiest?


Which subjects are hardest?


Does testing cause anxiety?


Do you or does the school consider your child to have a learning problem?


Do you or does the school consider your child to have a behavior problem?


Does your child like to read?


Practice Policies and Submit





NOTICE OF PRIVACY PRACTICES

Our practice is committed to educating our patients about healthcare issues that affect them. As a result, we are providing you with general information about the Privacy Ruler, a federal regulation of the Health Insurance Portability and Accountability Act of 1996 (HIPPA) along with a brief overview of our Notice of Privacy. We are complying with the HIPPA's regulations.

What is HIPPA and how does the Privacy Rule affect you?

When the Health Insurance Portability and Accountability Act (HIPPA) was passed in August 1996 this gave the federal government the ability to mandate how healthcare plans, providers and agencies send a patient's personal information as it relates to healthcare. The Privacy Rule was created to protect your rights as a patient of our practice and we are required by law to be compliant with this regulation on April 14, 2003. Under this rule you are guaranteed access to your medical records, allowed control over how your protected health information is used and disclosed and allowed to take action if your privacy is compromised by following the practice's policy. Our practice is dedicated to maintaining the privacy of your personal information.

What is Individually Identifiable Health Information (IIHI)?

Any health information you provide our practice, including your mailing address. Information that is created and retained by our practice or received by another healthcare provider that relates to treatment, payment and/or that identifies you as an individual.

What is the Notice of Privacy Practice (NPP)?

Our practice has an official Notice of Privacy Practice (NPP) posted in our waiting room informing our patients about their rights surrounding the protection of your IIHI and our obligations concerning the use and disclosure of your IIHI. This notice applies to all records created or retained by our practice. We can update our Notice Privacy Practices at any time. It will be posted in our waiting room and you can ask for a copy of the current notice at any time.

The following categories describe the different ways in which we may use and disclose your IIHI:

Treatment Payment Appointment Reminders Release of Information to Referring Sources * Treatment Options Disclosures Required by Law Health Care Operations * Health Related Benefits and Services Hearing Aid Companies
The following categories describe unique situations in which we may use or disclose your IHII:
Public Health Risks * Health Oversight Activities * Lawsuits and Similar Proceedings * Law Enforcement * Deceased Patients * Workers Compensation * Serious Threats to Health and Safety Research * Military National security * Inmates * Organ and Tissue Donation

What are your rights concerning your Individually Identifiable Health Information (IIHI)?

You have rights regarding the IIHI that we maintain about you. In our Notice of Privacy you can view the policies and procedures you will need to follow for the areas listed below.

1. Confidential Communications
2. Requesting Restrictions
3. Inspection and Copies
4. Amendment
5. Accounting of Disclosures
6. Right to a Paper Copy of this Notice
7. Right to File a Complaint
8. Right to Provide an Authorization for Other Uses and Disclosures

If you have any questions regarding this notice or our health information privacy policies, please contact: Peter Charron, OD of Northwest Vision Development Center: 1616 Cornwall Ave Ste. 105 Bellingham, WA 98225 ______________________________________________________________________________________________________________________________________________________

OUR POLICY OF CARE and PAYMENT

Our goal at the Northwest Vision Development Center is to provide the best vision care service and products that satisfy our patients' needs at a reasonable price.

FULL PAYMENT FOR PROFESSIONAL SERVICES AND/OR MATERIALS IS DUE AT TIME OF SERVICE. Acceptable forms of payment include cash, personal check, Visa, Mastercard & debit cards. A $30 FEE WILL BE CHARGED FOR NSF CHECKS.

Unpaid balances on accounts will be invoiced through email. A 3.0% late penalty will be added to any uncollected balance after 30 days from the due date. Any unpaid balance that is over 90 days late will be sent to a collections agency unless other agreements with the office have been made in writing.

What if I Have Insurance? ***About Your Insurenace***:

There are two types of health insurance that will help pay for your eye care services and optical products. You may have both types and NW Vision Development Center may accept plans in both categories.

Vision plans only cover routine vision wellness exams, along with eyeglasses and contact lenses. Vision plans do not cover medical eye care (the diagnosis and management or treatment of eye health problems.

Medical insurance must be used for medical eye care, including therapy and rehabilitation.

If you have both types of insurance plans it may be necessary for us to bill some services to one plan and some services to the other.

Please provide your insurance cards to our staff member so we can make a copy. We need to have your medical insurance on file for future billings to your insurance.

Our clinic is contracted with a variety of insurance networks. All insurance eligibility must be presented and confirmed prior to the services. If eligibility for services cannot be verified, you will be responsible for payment in full for all services and materials at the time of your visit. All fees are the full responsibility of the patient/parent/guardian. If our office is contracted with your insurance, our office will file an insurance claim (HCFA 1500) on your behalf. However, it is your responsibility to pay in full for any services or materials not covered by your insurance plan. If you prepay for any service or materials, any insurance payments we receive at a later date will be credited to your account and/or refunded to you. If there are fees which are not collected on the date of service and are not paid by your insurance, we will bill you for them, such as deductibles, co-pays or non-covered services. Insurance codes for pre-determination of benefits will be supplied upon request.

Eyeglass and Contact Lens Return Policy:

  • Professional fees, such as therapy, exam fees, or contact lens evaluation/fitting fees, represent payments for services that were rendered (even if not successful) and are non-refundable.
  • Frames may be returned for exchange within 30 days if in perfect condition. The new charge will include the cost of the new frame less the cost of the returned frame. Note: New lenses are often required if the new frame is larger. If the frame requires new lenses, charges on the lenses will include the full cost of the new lenses plus an additional surcharge of 20% of the cost of the lenses.
  • Prepackaged contact lenses may only be returned if the original packaging is not opened or written upon.

Eyeglass Rx Changes:

  • For prescriptions written by other doctors: Eyeglass lenses will be remade one time at no charge if the prescribing doctor provides a new prescription in writing within 30 days of dispensing. Rx changes after one free remake or after 30 days will be charged the usual lens price.
  • For prescriptions written by doctors at NW Vision Development Center: An office visit to recheck the fitting/prescription will be provided and new lenses will be made at no charge within 30 days of dispensing. Recheck visits after 30 days will be charged the usual fee for a refraction test.
  • If a NW Vision Development Center prescription is filled elsewhere and an Rx change is needed, we will not be responsible for any charges incurred. Most reputable optical dispensaries allow doctor Rx changes at no charge, but it is up to the patient to inquire about such policies in advance of purchase.

Progressive Addition Lens Non-Adapt Policy:

  • All progressive addition lenses (also called invisible or no-line multifocals have a slight optical distortion in the outer portions of the lens, which can make some objects appear bowed or curved, or can cause a feeling of motion when the head is turned. The reading zone of progressive lenses is wide enough for most purposes, but it may be narrower than other bifocal styles. While most people are not bothered by these characteristics, some will find it unacceptable even after a one to two week adaptation period. If you cannot adapt to progressive addition lenses, we will make new lenses in any other design that you wish, within 30 days of dispensing, at no charge. Since the original lenses were a custom prescription item, there are no refunds of the difference in cost if the remade pair is of lesser value.

Policy for Making New Lenses for a Patient's Old Frame or Frame Purchased Elsewhere:

  • NW Vision Development Center cannot be responsible for breakage when we reuse a patient's old frame or frame purchased elsewhere to manufacture and insert new lenses.
  • NW Vision Development Center will use the utmost care if we accept a patient's frame, but in a small percentage of cases, the frame parts or material will be worn or brittle to the point that it will not support a new lens.
  • Older frames are usually discontinued by the manufacturer and replacement parts are generally not available. Putting new lenses into an old frame may create a pair of glasses that cannot be repaired later.
  • If a patient's frame breaks during our handling, the purchase of a new frame is the patient's expense. NW Vision Development Center may have to discard the first pair of lenses made for the original frame, but no additional charge will be applied for lenses.
***It is understood that should it become necessary for my account to be turned over for collections, I will be liable for any and all resulting collections and/or legal fees incurred. It is understood that failure on my part to adhere to this payment agreement will result in a break from treatment.

I acknowledge that I have read and received a copy of the foregoing agreement. I consent to treatment and I assume all financial responsibility for all treatment expenses.