Advanced Eye Care Center - Manhattan Beach
Patient Health HistoryPatient Name*
Date of Birth*
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State / Province / Region
ZIP / Postal Code
Home PhoneWork PhoneCell PhoneEmail
Social Security # Employer Occupation Primary Care Physician PCP PhoneMedical Insurance & Policy Number Spouse Name & Age Other Family Members Still Living at Home (names and ages) Whom may we thank for referring you to this office? Medical/Family HistoryPlease list all your current medications and eye drops (include over-the-counter, vitamins and herbal therapy) List all major surgeries (include Eye Surgery) List any allergies or allergic reactions to medications or eye drops Please indicate if any of the conditions apply to you or a family member (blood relatives only).Blindness
Which Family Member? Glaucoma
Which Family Member? Retinal Detachment
Which Family Member? Macular Degeneration
Which Family Member? Arthritis
Which Family Member? Cancer
Which Family Member? Diabetes
Which Family Member? Heart Disease
Which Family Member? High Blood Pressure
Which Family Member? Stroke
Which Family Member? Thyroid Disease
Which Family Member? Other condition not specified above: Review of SystemsPlease indicate below if you have or have ever had problems with the following conditions.Allergic/Immunologic
Other (i.e. Latex allergy)
High Blood Pressure
High Blood Cholesterol
Ear, Nose and Throat
Skin / Integumentary
Muscle / Skeletal
Genital / Urinary
Urinary Tract Infection
We respect our legal obligation to keep health information that identifies you private. We
are obligated by law to give you notice of our privacy practices. This Notice describes how we
protect your health information and what rights you have regarding it.
When it comes to your health information, you have certain rights. This section explains your
rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record You can ask to see or get an electronic
or paper copy of your medical record and other health information we have about you. Ask us
how to do this. We will provide a copy or a summary of your health information, usually within
30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record. You can ask us to correct health information about you
that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your
request, but we’ll tell you why in writing within 60 days.
Request confidential communications. You can ask us to contact you in a specific way (for
example, home or office phone) or to send mail to a different address. We will say “yes” to all
Ask us to limit what we use or share. You can ask us not to use or share certain health
information for treatment, payment, or our operations. We are not required to agree to your
request, and we may say “no” if it would affect your care. If you pay for a service or health care
item out-of-pocket in full, you can ask us not to share that information for the purpose of
payment or our operations with your health insurer. We will say “yes” unless a law requires us
to share that information.
Get a list of those with whom we’ve shared information You can ask for a list (accounting) of
the times we’ve shared your health information for six years prior to the date you ask, who we
shared it with, and why. We will include all the disclosures except for those about treatment,
payment, and health care operations, and certain other disclosures (such as any you asked us to
Get a copy of this privacy notice. You can ask for a paper copy of this notice at any time, even if
you have agreed to receive the notice electronically. We will provide you with a paper copy
Choose someone to act for you. If you have given someone medical power of attorney or if
someone is your legal guardian, that person can exercise your rights and make choices about
your health information.
File a complaint if you feel your rights are violated. You can complain if you feel we have
violated your rights by contacting us at (310)-568-0193. You can file a complaint with the U.S.
Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting
www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to 1) Share information with your family, close friends, or others involved in your care 2) Share information in a disaster relief situation 3) Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission: 1) Marketing purposes 2) Sale of your information 3) Fundraising - We may contact you for fundraising efforts, but you can tell us not to contact you again.Please sign below to acknowledge that this form is current.*Today's Date*
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