Accurate Family Vision New Patient

Waiver and Release of Liability Form. Acknowledgement and Assumption of Risk
Name of Patient
First Last
Name of Signer if Different from Patient
First Last
Relationship to Patient
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Home Phone
Daytime Phone
Cell Phone
Occupation/Employer
Hobbies
Hours Per Day on a Computer
How did you hear about our office?
Vision Insurance
Primary Insured Name
First Last
Primary Insured Date of Birth
MM slash DD slash YYYY
Relationship to Insured
Insurance Provider
Employers Name
Insured Identification Number
Insured Group Number
Medical Insurance
Primary Insured Name
First Last
Primary Insured Date of Birth
MM slash DD slash YYYY
Relationship to Insured
Insurance Provider
Employers Name
Insured Identification Number
Insured Group Number
Acknowledgement of Receipt of 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. Your protected health information (PHI) 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. We will obtain your written authorization for uses and disclosures of your PHI that are not identified in this Notice or are not otherwise permitted by applicable law. You may revoke an authorization at any time by sending us a written request however we are unable to retract previous disclosures. We May Use and Disclosure Your PHI WITHOUT Your Written Authorization For The Purpose Of: • Treatment- Examples include scheduling and reminders of appointments; examinations, case management or care coordination; prescribing/ordering of glasses, contact lenses, vision aides or medications and notification of order status; or to recommend treatment alternatives or other health-related products or services. • Payment-Examples include acquiring payment guarantor/insurance information; processing bills or claims; and collecting unpaid balances. • Health Care Operations-Examples include financial or billing audits; internal quality assurance including patient satisfaction surveys; personnel decisions; participation in managed care plans; legal defense; business planning; and outside storage of our records. Other Uses and Disclosures That Do NOT Require Written Authorization • As Required by Law – we will disclose PHI when required to do so by federal, state or local law. • Public Health Activities- for example contagious disease reporting, investigation or surveillance; and notices to and from the FDA regarding drugs or medical devices. • Victims of Suspected Abuse, Neglect or Domestic Violence- PHI may be disclosed to the appropriate government authorities. • Health Oversight Activities- such as audits, medical licensing, investigations, inspections or licensure. • Judicial and Administrative Proceedings- such as in response to subpoenas or court orders • Law Enforcement- such as disclosures about a suspected crime victim; to identify or locate a suspect, fugitive, material witness, or missing person; or about a crime committed in our office. • Coroners, Medical Examiners and Funeral Directors- to identify a deceased person; to determine the cause of death or to allow funeral directors to carry out their duties. • Organ and Tissue Donation- to facilitate organ, eye or tissue donation and transplantation, disclosures may be made to organizations that are involved in organ or tissue donation. • Research - when approved by an institutional review or privacy board that has reviewed the research proposal and its privacy protocols. Even without approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any PHI. • To Avert a Serious Threat to Health or Safety- PHI may be disclosed to protect others and will only be made to someone who may help prevent the threat, including the target. • Specialized Government Functions- such as the protection of the president or high ranking officials; lawful national intelligence activities; military purposes as required by military command authorities; the evaluation and health of members of the foreign service; in law enforcement custodial situations to provide health care or protect the health and safety of others. • Workers' Compensation- as required by law to workers' compensation or similar authorized 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 accordance with HIPAA Use and Disclosures of PHI to Family, Friends or Personal Representatives Unless you object, we may share relevant PHI with your family, close friends or personal representatives who are involved in your health care or payment of your health care. We may also notify them of your location or general condition. If you are not present or are incapacitated, we may use or disclose relevant PHI when, in our professional judgment, it is in your best interest. Specific Uses and Disclosures That REQUIRE Your Written Authorization • Marketing Activities – other than face-to-face communications or promotional gifts of nominal value requires, we may not use or disclose your PHI for marketing of products or services without your written notification IF we receive payment by third parties whose products or services are described. The written authorization must inform you that we are receiving compensation. • Sale of Health Information. We do not currently sell or plan to sell your health information and we must seek your written authorization prior to doing so. Your Rights Regarding Your PHI: • Right to Request Restrictions on Disclosures. You may send our office a written request to restrict or limit the PHI we use or disclose for treatment, payment, or health care operations or to limit the PHI we disclose to family members or friends involved in your care. We are not required to agree to all such requests. However, we must agree to requests to restrict disclosure of PHI to a health plan if the disclosure is for the purpose of carrying out payment or health care operations; if it is related to services that you have paid in full (e.g. out-of-pocket and without any third party contribution or billing); and is not otherwise required by law. • Right to Receive Confidential Communication. You may request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. Send a written request that specifies how or where you wish to be contacted to our office. We will accommodate reasonable requests. • Right to Inspect and Copy. You have a right to inspect and copy PHI that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. You may request a copy of your electronic health records in electronic format. All requests must be made in writing. Contact us for a copy of our authorization form. If copies of your records are requested, we may charge you a reasonable fee based on the cost of labor, supplies and mailing/delivery fees. • Right to Amend. If you feel that PHI we have is incorrect or incomplete, you may send a written request, including the reason for the amendment, to our office. • Right to an Accounting of Disclosures. You may request a list of certain disclosures of PHI, made within the past 6 years, for purposes other than treatment, payment and health care operations or for which you provided written authorization. Send a written request that includes the time period requested and how you would like the report delivered (paper or electronic) to our office. • Right to a Paper Copy of This Notice. To obtain a paper copy of this notice send a written request to our office. Our Duties We are required by law to: maintain the privacy of your PHI, give you this Notice of our duties and privacy practices regarding PHI information to notify affected individuals following a breach of their unsecured PHI and abide by the terms of the Notice currently in effect. If you have any questions please contact our office. Changes to This Notice: We reserve the right to change this Notice and make the new Notice provisions apply to PHI we maintain. A copy of our current notice will be posted in our office and copies will be available by request. Complaints: If you believe your privacy rights have been violated, you may submit a written complaint to our office or with the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint. Please direct any questions or requests to: Amy M. Lee, O.D. Accurate Family Vision 3570 S. Val Vista Dr. #104 Gilbert, AZ 85297 Ph: (480) 899-2381 Fx: (480) 899-1039
Signature of Patient or Parent/Legal Guardian

I have received a copy of this office's Notice of Privacy Practices Policy. Accurate Family Vision will maintain the privacy of our health information and personal data.
Date
MM slash DD slash YYYY
Statement of Financial Responsibility
I accept responsibility for payment in full for services rendered on the day of examination. If my insurance is accepted and does not reimburse the doctor's office, I understand I am responsible for payment. Exam fees are considered medical services and are therefore not refundable.
Signature of Patient or Parent/Legal Guardian
Eye & Health History
Have you ever been diagnosed with any of the following? Select all that apply
- Cataract
- Macular Degen.
- Glaucoma
- Diabetes
- Diabetic Retinopathy
- Dry Eye
- Eye Infection/allergy
- Inflammation
- Retina Defects
- Retina Degen.
- Lasik or RK
- Lazy Eye
Have you ever had eye surgery?
What eye surgery have you had?
Do you use any eye drops?
What do you use eye drops for and how often do you use them?
What kind of contacts have you used in the past?
- Disposable
- Toric
- Hard/Gas Perm
- Conventional Yearly
Name of contact lens brand?
When was the last time you wore your contacts?
How often do you replace your contact lenses?
Do you sleep in your contacts?
Are you experiencing any of the following eye/vision concerns? Check all that apply.
- Redness
- Burning
- Itching
- Tearing
- Discharge
- Blurred Vision
- Eyestrain
- Eye Pain
- Severe Light Sensitivity
- Headache
- Poor Night Vision
- Night Glare
- Double Vision
- Total Loss of Vision
- Flashes/Floaters
When was your last eye exam?
How old are your glasses?
Sunglasses?
Health History (select all that apply):
- Cancer
- Ear/nose/throat
- Neurological
- Anxiety/Depression
- Cardiovascular
- Respiratory
- Gastrointestinal
- Kidney Disease
- High Blood Pressure
- STD-Herpes/chlamydia
- Muscle/Joint/Bone Pain
- Skin
- Diabetes
- Thyroid
- Anemia
- Cholesterol
- Allergy/Immune
- HIV/Aids
If you answered yes to any of the above or have any condition not listed, please explain:
Please list any medications you are currently taking:
Do you have any sensitivity/allergy to any medications?
Social History
This information is strictly confidential. However, you may discuss this portion with the doctor if you prefer.
Do you drink alcohol?
How often do you drink?
Do you use tobacco products?
How often do you use tobacco products?
Do you use illegal drugs?
If yes, please list:
Are you pregnant?
Are you nursing?
Family History
Please indicate which family members have had any of the following conditions
Cancer
- Father
- Mother
- Brother
- Sister
- Son
- Daughter
- None
Kidney Disease
- Father
- Mother
- Brother
- Sister
- Son
- Daughter
- None
Diabetes
- Father
- Mother
- Brother
- Sister
- Son
- Daughter
- None
Thyroid Disease
- Father
- Mother
- Brother
- Sister
- Son
- Daughter
- None
Heart Disease
- Father
- Mother
- Brother
- Sister
- Son
- Daughter
- None
High Blood Pressure
- Father
- Mother
- Brother
- Sister
- Son
- Daughter
- None
Cataract
- Father
- Mother
- Brother
- Sister
- Son
- Daughter
- None
Macular Degen.
- Father
- Mother
- Brother
- Sister
- Son
- Daughter
- None
Retinal Detach
- Father
- Mother
- Brother
- Sister
- Son
- Daughter
- None
Glaucoma
- Father
- Mother
- Brother
- Sister
- Son
- Daughter
- None
Optomap
We are proud to introduce the latest in retinal imaging, the Optomap. It is painless, quick and the doctor’s preferred method of monitoring the health of your eye. This instrument will enhance our ability to detect and monitor retinal defects associated with common systemic diseases such as hypertension, diabetes, high cholesterol, and thyroid problems. Through this digital imaging of the retina, we can observe early changes in the eye relating to glaucoma, cataracts, and macular degeneration. Optomap can detect debilitating or potentially fatal disorders that can be present in the retina. This technology can be used without dilation, and will be a permanent part of your medical records. There are no side effects with this test.
This technology is our preferred way of monitoring the eye over time.
By the time you have symptoms affecting your vision, it is typically too late to prevent permanent sight damage. We care about your vision and want to be sure we actively monitor your eye; the optomap retinal image is the best way to do this. There is a nominal fee of $39 to perform this procedure. This includes dilation if the doctor deems necessary.
Signature of Patient/Guardian
Date
MM slash DD slash YYYY
Medical vs. Vision insurance explanation
Most people have vision insurance and medical insurance. They are very different in terms of the services they cover and it is important for our patients to understand those differences. Vision coverage (VSP, Spectera, EyeMed, Davis, ect….) is mainly designed to determine a prescription for glasses and is not equipped to deal with complex medical conditions and/or diagnosis. It does allow for screenings of conditions, but once they are determined, then medical insurance is filed on those services. When a medical condition is present (such as diabetes, cataracts, dry eye, floaters, etc.) it is necessary to file the visit with your major medical carrier (BCBS, Aetna, UHC, Cigna, etc.) and the co-pays for that insurance will apply. Insurance carriers set these rules and our office is required to follow them. In most cases, there is no way to know prior to the examination which type of insurance our office will be able to file for you. 1. If you have ANY problems or complaints that MAY be attributable to a medical condition which requires a more in-depth investigation and additional medical decision-making to rule out any underlying eye disease, we will accordingly bill your MEDICAL insurance, NOT you vision plan. These include, but are not limited to: • New or sudden blurry vision • Flashes or floaters • Dry or itchy eyes • Eyestrain or double vision • Eye pain or redness • Headaches • Loss of vision 2. There are a variety of systemic conditions that can profoundly and permanently affect a patient’s vision that require a more in-depth investigation, which may include additional testing, follow up visits, and reports to your primary care physician. This type of examination is NOT covered under “vision” plans, and we will bill your MEDICAL insurance, NOT your vision plan. These include, but are not limited to: • Diabetes • Hypertension • Thyroid disease • Lupus or autoimmune disease • Diseases resulting in use of high risk medications like Placquenil 3. If you have previously been diagnosed by another eye doctor for any eye issues that require medical decision-making, treatment or management, we will bill your MEDICAL insurance, NOT your vision plan. These include, but are not limited to: • Cataracts • Amblyopic/lazy eye • Glaucoma/previous diagnosis of high eye pressure • Macular or retinal disease • History of eye surgery We make every effort to be on every major carrier for your convenience and we will file those claims for you. In the event that we do not take you insurance we will provide you with an itemized receipt so that you may file with your carrier for reimbursement. If you have any question, please let us know
Signature
Date
MM slash DD slash YYYY
No Show Policy
We understand that situations may arise in which you will need to cancel or reschedule your appointment. However, each time a patient misses an appointment without providing the proper notice, another patient is prevented from receiving care. Therefore, any patient who fails to arrive for a scheduled appointment without canceling or rescheduling the appointment 24 hours prior to the scheduled appointment time is considered a No Show. Patients who No Show 3 or more times in a 12 month period will be charged a non-refundable $50 fee. No Show fees are the responsibility of the patient or guardian and must be paid in full before a new appointment will be scheduled. We appreciate your understanding and cooperation.

Accurate Family Vision New Patient

Waiver and Release of Liability Form. Acknowledgement and Assumption of Risk

Vision Insurance

Medical Insurance

Acknowledgement of Receipt of Notice of Privacy Practices

Statement of Financial Responsibility

Eye & Health History

Social History

Family History

Optomap

Medical vs. Vision insurance explanation

No Show Policy