Diane King O.D.

Have you seen Dr. King before?

Yes
No

*If YES, please provide any changes since your last visit.

Title

Gender

Male
Female

Name*

First MI Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Work Phone

Cell Phone*

Email Address*

*If this exam is for a minor, please provide responsible parent's email address.

Date of Birth*

SSN:

Marital Status

Single
Married
Other

Employer

Occupation

Vision Insurance

Insured's Full Name:

Insured's Date of Birth

Insured's SSN

Medical Insurance

Insured's Full Name

Insured's Date of Birth

Insured's SSN

Relationship to Insured

Due to changes in HIPAA Rules, we must now request the following additional information for our records.

Preferred Language

English
Spanish

Race

Ethnicity

Hispanic / Latino
Non-Hispanic / Latino

Preferred Method of Contact

Email
Postal
Telephone

Chief Complaint (Check all that apply)

Medical (Check all that apply)

What are you allergic to?

How long have you had diabetes?

How long have you had hypertension?

What part of the head do your headaches occur?

How often do your headaches occur?

When did your headaches start?

Do you get relief?

Do you take any medications?

Yes
No

List medications you take

Are you allergic to any medications?

Yes
No

To which medications?

Does anyone in your family have:

Glaucoma
Cataracts
Blindness
Diabetes
Hypertension
Heart Disease

Which family member has glaucoma?

Which family member has cataracts?

Which family member has blindness?

Which family member has diabetes?

Which family member has hypertension?

Which family member has heart disease?

Do you wear glasses?

Yes
No

When did you start wearing glasses?

How old is your current prescription?

Do you wear contact lenses?

Yes
No

How old are your present lenses?

Brand and Specifications of Lenses (If known)

Education

High School
Vocational School
College Degree

Living Arrangements

Do you drive?

Yes
No

Do you visual difficulty when driving?

Yes
No

Do you have problems with night vision?

Yes
No

Do you drink alcohol?

Yes
No

How often?

Occasional
1 per day
2-3 per day
4+ per day

Do you smoke?

Yes
No

How often?

Occasional
1/2 pack per day
1 pack per day
1+ pack per day

For how many years?

Have you ever had a blood transfusion?

Yes
No

Are there any confidential items you wish to speak with the Doctor about?

Yes
No

Initial

I certify that I and/or my dependents have insurance coverage and assign benefits directly to Diane A. King, OD. I authorize use of my signatture on all claim submissions. Dr. King may use my health information and may disclose such information to the above named insurance company for the purpose of ontaining payment for services and/or for determining insurance benefits.

Initial

If you have vision coverage for routine eye examinations or medical coverage for problem visits with a company with which we have a contract AND you provide us with all information needed to file the claim, we will gladly accept contracted payment from the plan. If you notify us after services are received, we will supply you with a receipts you can submit to your plan. Please remember that it is your responsibility to ensure all referral and certification procedures are followed.

Initial

Co-payments and overages are due on the day of services are received and when materials are ordered, we accept cash, checks, and credit cards to aid you in budgeting expenses. If for any reason the account should become delinquent I agree to pay all billing charges, interest charges, collection costs and reasonable legal fees.

Initial

The Health Insurance Portability & Accountability Act of 1966 ("HIPAA") is a federal program that requires all medical records be kept confidential. As required by HIPAA, we have prepared a Notice of Privacy Practices Policy. A Copy of the policy is available upon request. By signing below, you acknowledge that this information has been made available to you.

Signature