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Spectrum Eyewear Patient Registration
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2019-12-16T18:41:19+00:00
Spectrum Eyewear Patient Registration
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Step 1: Patient Registration
Patient
First
Last
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 Number
Work Phone Number
Cell Phone Number
Email Address
Sex
Male
Female
Brithdate
MM slash DD slash YYYY
Last 4 of SSN:
Occupation
Employer
Martial Status
Spouse's Name
Brithdate
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
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:
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
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
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
MM slash DD slash YYYY
Patient Name
First
Last
Patient Date of Birth
MM slash DD slash YYYY
Medication List
Allergies/Reactions:
Please list all Medications taken, the dosage and the frequency:
Patient Signature
Date
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
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.
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