Cooper Eye Care Manhattan

Step 1 of 5

Patient Information
Name
Last: First: Middle: Title:
Address:
Street Address City State ZIP Code
Date of Birth:
MM slash DD slash YYYY
Gender:
- F
- M
Marital status:
Preferred Name:
Cell Phone #:
Ok for text reminder:
- Y
- N
Secondary Phone #:
Email:
SSN:
Spouse (or emergency contact) Information
Name
First Last
Phone #:
Relationship to patient:
Reason for today's visit:
Today's Date:
MM slash DD slash YYYY
Patient (or Guardian's) Signature
Date:
MM slash DD slash YYYY
Responsible Party Signature
Relationship

Dear Patient,

The following insurance companies do not cover a glasses/contact lenses:

Medicare, Oxford, GHI, Cigna, UnitedHealthCare, Empire Plan

If you have VSP or EyeMed, these services WILL be covered or discounted depending on your insurance plan.

If you need a glasses/contact lens prescription, please check “yes”, if not check “no”. Be aware that the office will not have a valid prescription available for you now or in the future to obtain a new eyeglass or contact lens prescription if you decline these services.
Glasses Rx
- Yes, I need a prescription for glasses. I understand that there is a professional fee of $75 to determine an accurate prescription for glasses.
- No, I do not need a new prescription for glasses. I understand without a new refraction, glasses Rx cannot be prescribed for me.
Contact Lens Rx
- Yes, I need a prescription for contact lenses. I understand that there is a professional fee to determine an accurate prescription for contacts. The fees vary depending on the type of fitting and can range from$105-$400. Specialty fittings can go up to $2,350. • Contact Lens Evaluation $105 (Already wearing lenses and need to update prescription) • Contact Lens New Fitting $285-$355 (Never worn lenses before). • Contact Lens Refit $205-$375 (A contact lens wearer whose current brand of lenses need to be changed and maybe based on the doctor's decision during the exam).
- No, I don’t need, nor will I need a prescription for new contacts. I understand without a new evaluation, contact lens can NOT be prescribed.
Name
First Last
Date:
MM slash DD slash YYYY
Signature:
Date:
MM slash DD slash YYYY

539 Park Ave, New York, NY 10065

P: (212)-758-0772, F: (212)-758-3532

1452 86th Street, Brooklyn, NY 11228

P: (718)-265-2020, F: (718)-837-0431

www.coopereyecare.com

Authorization for Use and Disclosure of Protected Health Information

By signing this Authorization, you authorize Cooper Eyecare to use and disclose your protected health information (“PHI”), including your name, your address and information about the vision care you received (such as examinations, contact lenses and glasses), to TeamVision, so that TeamVision can provide you with information about products and services that may interest you.

Additionally, you acknowledge and agree to the following:
- I understand that I do not need to sign this Authorization to receive treatment, services, or materials from TeamVision.
- I understand that TeamVision may receive direct or indirect remuneration from another party in connection with the use or disclosure of my PHI for the purpose described above.
- I understand that I may receive a copy of this Authorization. (Refer to front desk for emailed copy).
- I understand that the PHI subject to this Authorization may be protected by law. I understand that such PHI may be re-disclosed by TeamVision and no longer protected by the federal health information privacy law known as HIPAA. However, certain state laws may prohibit TeamVision from further disclosing my information to another party, unless another authorization is obtained from me or unless further disclosure is specifically permitted or required by law.
- I understand that I have the right to revoke this Authorization in writing at any time by emailing TeamVision.
- Revoking this Authorization will not have any effect on actions in reliance on the Authorization before the notice of my revocation was received.
- I understand that this Authorization will terminate two (2) years from the date on which I agree to this Authorization, unless I revoke it sooner.
Signature:
Printed Name:
First Last
Date:
MM slash DD slash YYYY

Cooper Eye Care Manhattan

Step 1 of 5

Patient Information

Spouse (or emergency contact) Information

Authorization for Use and Disclosure of Protected Health Information

OPTOMAP (Retinal Image)

Consent Form

Price of the OPTOMAP: $75

Price will vary depending on the coverage from insurance

PRIVACY ACKNOWLEDGMENT

Cooper Eye Care Manhattan

Step 1 of 5

Patient Information

Spouse (or emergency contact) Information

Authorization for Use and Disclosure of Protected Health Information

OPTOMAP (Retinal Image)

Consent Form

Price of the OPTOMAP: $75

*Price will vary depending on the coverage from insurance*

PRIVACY ACKNOWLEDGMENT

Price will vary depending on the coverage from insurance