Excel Eye Care of Texas – Patient Registration Form

Excel Eye Care of Texas - Patient Registration Form

PLEASE FILL IN THIS FORM ONLY IF YOU ARE A NEW PATIENT OR YOUR INFORMATION HAS CHANGED SINCE YOUR LAST VISIT.
EXCEL EYE CARE OF TEXAS

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operation.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting us by phone at (817) 806-9848 or by email at reception@exceleyecareoftexas.com.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us a written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance of this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.
Name of patient
First Last
Date of Birth
MM slash DD slash YYYY
LAST 4 OF SSN (only if using insurance)
Home Phone (Optional)
Cell
Email
When available, I consent to receive my prescriptions electronically
- Yes
- No
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
SIGNATURE: I have had full opportunity to read and consider the contents of this Consent and Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.
Signature

Please type your name to sign. (If patient is under 18 years, signature of parent, guardian, or personal representative)
VISION INSURANCE: we can bill VSP, Spectera and Costco employees' insurance - if you do not have one of these please disregard this section. For those with other insurance, we will still give you a paid invoice to submit to your insurance for reimbursement.
Please put your vision insurance company here (ONLY if you have VSP, Spectera, or Costco employee plans)
Please put your vision insurance ID# here, or put "unknown" if you don't know it
If the patient being seen is not the primary insurance holder, please put the primary's information below:
Name
First Last
Date of Birth
MM slash DD slash YYYY
LAST 4 OF SSN

Excel Eye Care of Texas - Patient Registration Form

PLEASE FILL IN THIS FORM ONLY IF YOU ARE A NEW PATIENT OR YOUR INFORMATION HAS CHANGED SINCE YOUR LAST VISIT.

VISION INSURANCE: we can bill VSP, Spectera and Costco employees' insurance - if you do not have one of these please disregard this section. For those with other insurance, we will still give you a paid invoice to submit to your insurance for reimbursement.