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Bellingham Family Eye Clinic Registration Form
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2019-08-28T23:48:09+00:00
Bellingham Family Eye Clinic
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Name
First
Last
How do you wish to be addressed?
Date of Birth
MM slash DD slash YYYY
Gender
Female
Male
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Phone
Cell Phone
Work Phone
Patient or Parent Social Security Number
Email Address
Patient Occupation (If student, list grade, school and teacher)
Employer
I currently wear
glasses
contacts
Who prescribed them?
Responsible Party (for Children under 18)
Who may we thank for referring you to us?
We are committed to providing you with the best possible care. If you have medical / vision insurance we are eager to help you receive your maximum allowable benefit. It is your responsibility to understand your insurance benefits (some insurance companies that we are contracted with have added a vision plan that is separate from the major medical and we may not be providers). If we are not contracted with your insurance we may file a claim as a courtesy. All unpaid balances are patient responsibility. If you would like us to bill your insurance you must provide a copy of the insurance card.
Name of Insurance
Member ID Number
Name of Subscriber
Date of Birth
MM slash DD slash YYYY
Subscriber Social Security Number
If you are not contracted with your insurance and do not submit a claim, we will offer you a cash discount. We would ask that payment be made when services are rendered. We will provide an insurance bill that you can send in to your insurance company for reimbursement.
I understand that I am responsible for payment of any charges not covered by my insurance.
I authorize payment of healthcare benefits to this clinic.
I also authorize release of any medical records necessary to process any claims.
Full payment for services, glasses and contacts is due when received. THANK YOU!
Full payment for services, glasses and contacts is due when received. THANK YOU!
Patient Health History
Date of Last Exam
MM slash DD slash YYYY
Hobbies/Activities
What is your main reason for coming here today?
Glasses
Contacts
Lasik Information
Annual Exam
Medical or Health Concerns
Do you or your immediate family (parents/siblings/children) have any of the following conditions?
Allergies
Amblyopia
Respiratory (lung) disease
Cancer
Diabetes
Elevated Cholesterol
Heart Problems
Turned Eye
Color "blind"
High Blood Pressure
Thyroid
Migraine Headahces
Head Trauma
Liver Disease
Renal (kidney) Disease
Dry Eyes
Floaters/Spots
Flashing Lights
Retinal Detachment
Glaucoma
Cataracts
Macular Degeneration
Blindness
Have you ever had eye surgery or injury?
No
Yes
If yes, please explain
Are you currently taking any medications?
No
Yes
If yes, please list
Are you currently under a physician's care for a medical condition?
No
Yes
If yes, please note doctor's name and condition
Any allergies to medications?
No
Yes
If yes, please list
Do you experience any of the following (with your correction if you wear glasses or contacts)?
Distance vision isn't clear
Near vision isn't clear
Double vision
Night vision difficulties
Problems with glare
Eye pain
Are you pregnant or nursing?
No
Yes
Do you drive?
No
Yes
Describe any difficulties
Do you use tobacco?
No
Yes
Type and Amount
Do you drink alcohol?
No
Yes
Have you been exposed to any communicable diseases?
No
Yes
Financial Policies
Our intent is to provide you with the highest level of service and care. Part of this service is offering an explanation of our financial policies.
1. It is important for patients to be informed consumers who understand the specifications of their insurance policies. Your health insurance policy is a contract between you and the insurance company.
2. Each individual patient is responsible for all payment obligations arising out of treatment and care and guarantees payment for these services. You are responsible for deductibles, co-payments, co-insurance or any other patient responsibility indicated by your insurance carrier.
3. Our office may check eligibility, however you will be held responsible for knowing the extent and specifics of your specific insurance policy. Please note that some insurance companies contract with third party carriers for routine vision coverage, and Dr. Green may not be contracted with those vision carriers. Always verify with your insurance company that Dr. Green is a preferred provider in order to get the best benefits possible.
4. Your insurance company makes a final determination of benefits when they receive our billings. Any statements made by our staff regarding your coverage are made in good faith but may not be completely accurate even if we have your insurance information to verify coverage.
5. If there are any problems between you and your insurance company, you may file a grievance directly with your insurance company.
6. If payment has not been received within four months on an outstanding balance, the account may be sent to a third party collection agency. NSF checks or rejected credit card payments will be charged a service fee of $30.00 per occurrence.
7. Please feel free to ask any financial questions you may have. Again, our intent is to provide you with the highest level of service and care.
By signing below, I acknowledge that I understand the policies as contained herein.
Signature
Date
MM slash DD slash YYYY
NOTICE OF PRIVACY PRACTICES
I acknowledge that I have had the opportunity to review the updated Notice of Privacy Practices and Patient Consent form of Bellingham Family Eye Clinic PS. effective date 07/11/2019. I may request a copy if I desire one for my own records.
Name
First
Last
Signature
Date
MM slash DD slash YYYY
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