Accurate Family Vision New Patient

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

Read Before Signing*

Company has taken all precautions recommended by the Centers for Disease Control and Prevention for business who are continuing to provide services to customers during the COVID-19 crisis. This includes the Interim Guidance for Businesses and Employers to Plan and Respond to Coronavirus Disease 2019 (COVID-19) and Cleaning and Disinfecting Facilities. (https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-business-response.html) Additionally, Company has been screening our employees before every work shift to ensure that no employee is suffering any of the known symptoms of COVID-19, including running a fever, having a dry cough, or experiencing shortness of breath. However, it is also known that those without symptoms may still be capable of infecting others as an asymptomatic individual with COVID-19 and despite precautions taken the virus may still be present and capable of infecting individuals.

Knowing this information, I voluntarily elect to continue with my scheduled appointment with Company and I hereby agree to accept and assume any and all risks of personal injury or death.

Waiver of Liability and Indemnification
In consideration for being treated by Company, on behalf of myself, my personal representatives, heirs, next of kin, successors and assigns, I forever:

waive, release, and discharge Company, its agencies, officers, and employees from any and all negligence and liability for my death, disability, personal injury, or claims of any nature which may hereafter accrue to me, and my estate as a direct or indirect result of my participation in the above referenced appointment; and defend, indemnify, and hold harmless Company, its agencies, officers and employees, from any and all claims of any nature, including all costs, expenses, and attorney's fees, which may in any manner result from or arise out of this agreement, except for claims resulting from or arising out of Company willful or intentional negligence.

This release, indemnification, and waiver shall be construed broadly to provide a release, indemnification, and waiver to the maximum extent permissible under applicable law.

I, the undersigned, affirm that I am at least 18 years of age and am freely signing this agreement or that I am signing on behalf of a minor child that I have the legal authority to sign such agreements on behalf of. I have read this form and fully understand that by signing this form I am giving up legal rights and/or remedies which may otherwise be available to me regarding any losses I may sustain as a result of my appointment. I agree that if any portion is held invalid, the remainder will continue in full legal force and effect.

I agree to the privacy policy.

Name of Patient

First Last

Name of Signer if Different from Patient

First Last

Relationship to Patient

Coronavirus Screening Questions

Have you felt like you have had a fever, flu-like symptoms, persistent shortness of breath, or an abnormal dry cough in the past two months?*

Yes
No

Have you traveled outside of the US within the last 4-6 weeks?*

Yes
No

Have you been in close contact with an individual, including a health care worker, who has confirmed COVID-19?*

Yes
No

Have you ever tested positive for COVID-19?*

Yes
No

We are currently requesting If you marked YES to any of the above questions that you please contact the office right away to discuss and/or possibly reschedule your exam for a later date. We are dedicated to providing a safe environment for our patients and staff and appreciate your understanding and participation. Please sign and return this form at your appointment.*

I attest that to the best of my knowledge the following answers are true and correct. Patient/Guardian signature

Date*

Date of Birth

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

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

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

Statement of Financial Responsibility

Signature of Patient or Parent/Legal Guardian

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.

Eye & Health History

Have you ever been diagnosed with any of the following? Select all that apply

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.

When was your last eye exam?

How old are your glasses?

Sunglasses?

Health History (select all that apply):

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 $29 to perform this procedure. This includes dilation if the doctor deems necessary.

Signature of Patient/Guardian

Date

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

I understand the document above and authorize Dr. Lee and Accurate Family Vision Pllc. to file my insurance by the above guideline

Date