EyeCare Professionals, P.A.

Date

Name*

First Middle Last

Date of Birth*

Age

Sex

Male
Female

Home Phone

Work Phone

Cell Phone

Address

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

Social Security #

Email

Employment

Employer

School

Marital Status

Spouse's Name

First Last

Spouse's Date of Birth

Who referred you to our clinic?

What is the reason for your visit?

Emergency Contact

Emergency Contact Phone

Is the patient the person responsible for the bill?*

No
Yes

Responsible Party Name

First Last

Address

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

Social Security Number

Relationship to Patient

Employer

Home Phone

Work Phone

Cell Phone

Insurance Coverage

Vision Plan
Chips
Medicare
Medicaid
No Insurance
Other

Please specify your insurance company:

Primary Insurance:

Secondary Insurance:

Policy Number

Is the patient the policy holder?

No
Yes

Policy Holder Name

First Last

Address

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

Date of Birth

Social Security #

Consent to Treat/Authorization to Release Information

I authorize the Physicians of Eyecare Professionals, P.A. (Practice) to provide treatment and use my health information for treatment, payment, and healthcare operations, which includes submitting information to my insurance company for the purpose of processing claims. I further authorize non-Practice labs, radiology centers, Pathologists, and Radiologists who may interpret and/or report on diagnostic tests ordered by Practice to provide such treatment and use my health information for billing and payment. I am responsible for payment of services rendered to me by Practice. If I am under 18, parent/guardian requesting treatment assumes responsibility. Full payment is due at the time of service unless I am covered by an accepted insurance or third party coverage plan. I understand that if my account should ever require action by a collection agency in order to collect the balance owed, fees charged by these agents may be added to the balance due on my account.

I hereby acknowledge and agree to accept the policies stated above.

Signature of Patient or Parent/Guardian*

Lifestyle Vision Questionnaire

We recognize that your eyes are very important to you. We would like to know how you use your eyes on a daily basis. Along with your eye exam, this information will assist us in recommending the best options for your eyes and your personal Lifestyle Vision.

Do you wear glasses now?

Yes
No

When do you wear your glasses?

All the time
Sometimes
Only for Far Distances
Only for Reading
Only for the Computer

Check the activities that you currently do on a regular basis

Which of the activities you checked would you like to do without glasses, if possible?

How important is it for you to read or use the computer without glasses?

Very Important
Important
Not Important

How many hours per day do you read?

How many hours per day do you use the computer?

Where do you hold your book when reading?

Close to your face
Chest level
In your lap

How do you feel about wearing glasses?

If it were possible to go without glasses most of the time, would you like that?

Yes
No

Do you drive at night?

Yes
No

How often?

Occasionally
Nightly
As a profession (truck, cab, etc.)

What occupational, recreational, or other activities do you currently engage in that are not listed above?

How would you describe yourself?

Easy Going
A Perfectionist
A little of each

Authorization to Disclose Health Information

I authorize Eyecare Professionals, P.A. to disclose the patient's health information as described below.

The type and amount of information to be disclosed is as follows (include dates):

I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

This information may be disclosed to and used by the following individual or organization:

For the purpose of:

I understand that I have a right to revoke this authorization at any time.

I understand if I revoke this authorization I must do so in writing and present my written revocation to Bobby Moss. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

Unless otherwise revoked, this authorization will expire on the following date, event, or condition:

If I fail to specify an expiration date, event, or condition, this authorization will expire in six months.

I understand that authorizing the disclosure of this health information is voluntary.

I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information I can contact Bobby Moss at 601-366-1085 or 866-366-1085.

Signature of Patient or Legal Guardian

Patient Consent for Use and Disclosure of Protected Health Information

With my consent, EyeCare Professionals, P.A. may use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operations (TPO). Please refer to EyeCare Professionals, P.A. Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. EyeCare Professionals, P.A. reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to EyeCare Professionals, P.A.'s Privacy Officeer at 1501 Lakeland Drive, Suite 100, Jackson Mississippi 39216.

With my consent, EyeCare Professionals, P.A., may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, optical goods ordered, and any call pertaining to my clinical care, including laboratory results among others.

With my consent, EyeCare Professionals, P.A. may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards, and patient statements, as long as they are marked personal and confidential.

With my consent, EyeCare Professionals, P.A. may e-mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that EyeCare Professionals, P.A. restrict how it uses or discloses my PHI to carry out TPO.

However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to EyeCare Professionals, P.A.'s use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent taht the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, EyeCare Professionals, P.A. may decline to provide treatment to me.

Signature of Patient or Legal Guardian*

Patient Financial Responsibility Disclosure Statement

Your signature below forms a binding agreement between EyeCare Professionals, P.A. (the provider of vision services) and the Patient who is receiving vision services, or the Responsible Party for minor patients (those patients under 18 years old). Responsible Party is the individual who is financially responsible for payment of medical bills.

All charges for services rendered are due and payable at the time of service.

VISION/MEDICAL INSURANCE: We have contracts with many insurance companies, and we will bill them as a service to you. As the responsible party, you are responsible if your insurance company declines to pay for any reason.

The person signing on behalf of the Patient as the Responsible Party must:

* Inform Eyecare Professionals of the current address and phone number for the patient and the responsible party.
* Present all current insurance cards prior to each office visit.
* Verify at each visit that the information is current by signing our data sheet.
* Pay any required copay at the time of the visit.
* Pay any additional amount owing within 30 days of receiving a statement from our office. (When Eyecare Professionals receives an explanation of benefits (EOB) from your insurance company, any amounts that you need to pay will be billed to you).

Returned Check Policy
If a payment is made on an account by check, and the check is returned as Non-Sufficient Funds (NSF), Account Closed (AC), or Refer to Maker (RTM), the patient or the Patient's Responsible Party will be responsible for the original check amount in addition to a $25.00 Service Charge. Once notice is received of the returned check, Eyecare Professionals will send out a letter to notify the Responsible Party of the returned check. If a response is not made within 15 days from the letter date by the patient or the Responsible Party, the account may be turned over to our collection agency and a collection fee will be added to the outstanding balance - in addition to the $25.00 Check Service Charge.

Non-Payment on Account
Should collection proceedings or other legal action become necessary to collect an overdue account, the patient or the patient's Responsible Party, understands that Eyecare Professionals has the right to disclose to an outside collection agency all relevant personal and account information necessary to collect payment for services rendered. The patient, or the patient's Responsible Party, understands that they are responsible for all costs of collection including, but not limited to, interest due at 18% APR, all court costs and Attorney fees, and a collection fee will be added to the outstanding balance. By signing below, you agree to accept full financial responsibility as a patient who is receiving medical services, or as the responsible party for minor patients. Your signature verifies that you have read the above disclosure statement, understand your responsibilities, and agree to these terms.

Responsible Party Signature*