Spectrum Eyewear Patient Registration

Step 1 of 5

Step 1: Patient Registration
Patient
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone Number
Work Phone Number
Cell Phone Number
Email Address
Sex
- Male
- Female
Brithdate
Date Format: MM slash DD slash YYYY
Last 4 of SSN:
Occupation
Employer
Martial Status
Spouse's Name
Brithdate
Date Format: MM slash DD slash YYYY
Last 4 of SSN:
Occupation
Spouse's Employer
In Case of Emergency, Contact
Name
First Last
Relationship
Home Phone Number
Alternate Phone Number
Primary Care Physician
Who may we thank for your referral?
Signature
Date
Date Format: MM slash DD slash YYYY

Family History
Please note any family member with the following disease/conditions:
M-Mother; F-Father; Brother/Sister; MGM-Maternal Grandmother; MGF-Maternal Grandfather; PGM-Paternal Grandmother; PGF-Paternal Grandfather; Aunt/Uncle
Arthritis:
Blindness:
Cancer:
Cataracts:
Crossed Eyes:
Diabetes:
Glaucoma:
Heart Disease:
Hypertension:
Retinal DZ:
Social History
Health Habits: Select which substances you use and note consumption.
Alcohol:
- Yes
- No
Quantity:
Drugs:
- Yes
- No
Quantity:
Tobacco:
- Yes
- No
Quantity:
Number of years used:
If former, when did you quit?
Select conditions you currently have:
If selected other, please list:
Surgeries: Please indicate R/L or Bilateral where appropriate
Ocular History: Please indicate any ocular conditions you currently have, or none:
Ocular Surgeries: (Please indicate right or left)
Patient Signature Attesting To Accuracy Of Medical History:
Insurance
Please present insurance card to front desk. Assignment and release.
I, the undersigned certify that I (or my dependent) have insurance coverage with
And assign directly to Lakeshore Eyecare all insurance benefits, if any otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by the insurance. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize the use of this signature on all insurance submissions.
Date
Date Format: MM slash DD slash YYYY
Medicare Authorization
I request that payment of authorized Medicare benefits be made on my behalf to Lakeshore Eyecare for services furnished me by Lakeshore Eyecare. I authorize any holder of medical information about me to release to the Division of Medicare and Medicaid Services and its agents any information needed to determine those benefits payable for related services. I understand my signature request that payment be made and authorizes release of medical information necessary to pay the claim. If "other health insurance" is indicated in item 9 of the HCFA - 1500 form or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the medicare carrier as the full charge, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.
Beneficiary Signature
Date
Date Format: MM slash DD slash YYYY
Patient Name
First Last
Patient Date of Birth
Date Format: MM slash DD slash YYYY

Medication List
Allergies/Reactions:
Please list all Medications taken, the dosage and the frequency:
Patient Signature
Date
Date Format: MM slash DD slash YYYY

HIPAA CONSENT FORM
Spectrum Eyewear Gallery, Inc., provides this Consent to comply with the Privacy Regulations issued by the Department of Health and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you as our patient. By law, we are required to make sure that your protected health information is kept private. This is a summary of our Notice of Privacy Practices. You have the right to review our Notice before signing this Consent upon request. The terms of our Notice may change and you may obtain a revised copy by contacting our office. If you ever believe your privacy rights have been violated, you may file a complaint with the Compliance Officer of Spectrum Eyewear Hallery, Inc., or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing complaints. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. How will we use or disclose your information? Here are a few examples: -For vision, medical eye treatment and referral -To obtain payment and file insurance -In emergency situations -For appointment and patient recall reminders -To run our practice more efficiently and ensure all our patients receive quality care -For research and education -Prevent serious threats to health and safety - For organ and tissue donation -For workers compensation programs -In response to certain requests arising out of lawsuits or other disputes You have certain rights regarding the information we maintain about you. These rights include: -The right to inspect and copy -The right to amend -The right to an accounting of disclosures -The right to request restrictions -The right to a paper copy of this notice -The right to request confidential communications
By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations.
You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. Spectrum Eyewear Gallery, Inc., may condition treatment upon the execution of this Consent. Additionally, by signing this form, you acknowledge that by presenting yourself as a patient or child you consent for vision and medical eye care by the doctors and staff of Spectrum Eyewear Gallery, Inc. You hereby grant full authority to the optometrists/ophthalmologists, and their respective assistants to administer and perform any and all drugs, treatments, tests, or diagnostic procedures to or upon me, which may be advised, or necessary. This information and Notice of Privacy Practices is made available on request.
Patient
First Last
Last 4 of SSN
Signed By
First Last
Date
Date Format: MM slash DD slash YYYY
Relationship
(if other than patient)

At Spectrum Eyewear Gallery, we value each and every one of our patients. We want you to be 100% satisfied with the quality of your eyewear and the way you look. Please keep in mind that if you are unsure of your purchase, Spectrum has a hold policy, where we can hold the frame for up to two weeks at no charge to you. Spectrum offers a one-year, one-time manufacturer's replacement warranty on all of our frames and lenses. All items returned for warranty replacement must be presented for return.
If the prescription of your glasses needs to be altered, we will replace the lenses at no charge to you within 30 days of dispense. If you decide within 24 hours of your purchase that you are no longer satisfied with what you have selected, please notify the office and you will be issued an in-store credit for the full amount of what you paid. If you decide after the 24 hour time period that you are not happy with what you have chosen, you may choose a new frame. You will be responsible for any additional cost above the amount of the original frame. Spectrum will split the cost of the new lenses with you. Contacts may be returned for store credit as long as the box remains unopened.
By signing this document you have acknowledged Spectrum Eyewear Gallery's policy that all sales are final and that the form of payment used may not be replaced with any other form of payment or insurance after the sale, and that no refunds will be issued.

None
Anxiety
Arthritis
Asthma
Atrial Fibrillation (Irregular Heartbeat)
Bone Marrow Transplant
BPH
Breast Cancer
Colon Cancer
COPD
Coronary Artery Disease
Depression
Diabetes
End Stage Renal Disease
GERD
Hearing Loss
Hepatitis
Hypertension
HIV/AIDS
Hypercholesterolemia
Hyperthyroidism
Hypothyroidism
Leukemia
Lung Cancer
Lymphoma
Migraine Headaches
Prostate Cancer
Radiation Treatment
Seizures
Stroke
Other

Spectrum Eyewear Patient Registration

Step 1 of 5

Step 1: Patient Registration

In Case of Emergency, Contact

Family History

Social History

Insurance

Medicare Authorization

Medication List

HIPAA CONSENT FORM