Target Optical Patient Intake Form

Patient Name
Legal First Name Last Preferred Name
Appointment Date
MM slash DD slash YYYY
Patient Intake Form
Reason for Visit:
Check next to the options if a doctor has diagnosed you with any of these eye conditions:
- Cataract
- Age-related Macular Degeneration
- Glaucoma
- Diabetic Retinopathy
- Dry Eye
- Eye infection, inflammation, or allergy
- Floaters and/or flashes of light
- Iritis or Uveitis
- Retina Defects or degnerations
- Eye Injury
- Have you ever had an eye surgery?
Are you having any of the following eye concerns?
- Redness
- Burning
- Itching
- Tearing
- Discharge
Are you having any of the following vision concerns?
- Blurred vision
- Eyestrain
- Eye pain
- Severe sensitivity to light
- Headache
- Poor night vision
- Bothersome night glare
- Double Vision
- Total loss of vision
Do you currently, or have you ever had any of the following?
- Diabetes
- High Blood Pressure
- Heart Disease
- High Cholesterol
- Thyroid Dysfuntion
- Asthma
- Cancer
Please list any medications taken, prescription or over the counter:
Please list any allergies you have, medication or other:
Are there any eye conditions or health problems that run in your family?
(Cataracts / Glaucoma / Macular Degeneration / Diabetes / Hypertension / Thyroid Dysfuntion / etc.)
Please list any additional comments or concerns:
HIPAA notice and Insurance
Patient's DOB
MM slash DD slash YYYY
Gender
- Male
- Female
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Are you using insurance today?
- YES
- NO
(if yes, please fill out information below)
Name of primary card holder for the insurance
First Last
Primary DOB
MM slash DD slash YYYY
Gender
- Male
- Female
This person's relation to today's patient
Employer
Insurance Name
Group Name or # (if listed on card)
Member ID # (if listed on card)
Last 4 of primary card holder's SS
Acknowledgement of Receipt of Privacy Notice
By signing this acknowledgement of Receipt of Notice of Privacy Practices (the "Notice"); I acknowledge and agree that I have received a copy of the Notice of Privacy Practices for review and to keep for my records on the date identified below (available online at www.JohnRileyOD.com).

I understand that the Location may use and disclose necessary personal health information (for example, my name, address, subscriber identification number, eye exam information and/or type of products provided) to another party to permit the Location to perform its administrative duties, provide me with eye care services and products, process my vision benefit claims and communicate with me regarding vision care services provided by the Location (for example: mailing of exam reminders or information about services provided by the Location).

I can be assured that this Location does not sell my personal health information of any kind to a third party for such party's own use. I acknowledge and agree that the Location may submit my vision benefit claims to my health plan to receive reimbursement directly for the services and products that I have received from the Location.
Patient Signature or Patient's Legal Representative
AUTHORIZATION FOR THE USE AND DISCLOSURE OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION
I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that the information I authorize as a person or entity to receive may be re-disclosed and no longer protected by federal privacy regulations.

1. Persons/Organizations authorized to use or disclose the information: Office of Dr. John A Riley, OD
2. Persons/Organizations authorized to receive the information: Target Optical
3. Specific description of information that may be used/disclosed: My name, address, telephone number, email address, and next appointment date(s) and time(s).
4. As part of our recall program, the information will be used/disclosed for the following purposes:
a) For the purpose of providing Target Optical coupons and service and product information either from this office or directly from Target Optical; and
b) To compare mailing lists with Target Optical to help avoid duplicate mailings
5. I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment, receive payment or eligibility for benefits unless allowed by law.
6. The organization authorized to use/disclose the information will receive compensation for doing so: No
7. I understand that I may inspect or copy the information used or disclosed.
8. I understand that I may revoke this authorization at any time by notifying the person/organization providing the information in writing except to the extent that: a) action has been taken in reliance on this authorization; or b) if this authorization is obtained as a condition for obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy.
9. This authorization expires four years from the date of my signature.
Patient Signature or Patient's Legal Representative
Date
MM slash DD slash YYYY
CONTACT LENS POLICIES
DO YOU WANT TO GET A CONTACT LENS EXAM TODAY? (check)
Yes
No
If you decide to be fit for contacts later, you have 90 days from date of exam to begin the fitting process. If you return contacts after 3 months, but before 6 months, you will have to pay for a refraction ($25) plus the fitting fee. If you return for contacts after 6 months from the exam, you will have to have a new exam and fitting done.
Initial:
**If "yes" read contact lens policies below, if "no" then drop down to "Billing/Payment" section
Contact Lenses (CL's) are considered "medical devices" and are regulated by the FDA. Careless handling may lead to serious infection, permanent damage to your eyes, and even permanent vision loss. Due to this risk, it is recommended that all CL wearers have a current pair of glasses for use when CL wear is not desired or safe.

A CL fitting shall include: all trial contact lenses, a CL starter cleaning kit, and all follow up visits needed to obtain the final CL prescription. This policy requires good compliance of follow up visits by the patient, and is limited to 90 days from the start of fitting process. If the patient does not return for scheduled follow up visits, or returns after the 90 day period to attempt to finish the CL fitting process, an additional follow up visit charge will be added, or a new exam may be required in order to finalize the CL prescription.

All new CL wearers will be trained how to insert, remove, clean, and disinfect their contacts before they can take their trial lenses home. Each patient must be able to insert and remove their contacts before they leave with the trial contacts. Once a patient has taken home their trial contacts, no refunds will be given for the CL fitting.

Patients that have previously been fit for contact lenses may want to know why they are being charged for a "fitting" when they already know which contacts they have/want. The fitting fee covers not only the initial fit of the contacts, but any adjustments needed within 90 days of the exam. If, for example, a new contact lens is released within the 90 day fitting period, and the patient returns, wanting to try the new contact, there would be no additional charge to try this new lens. Furthermore, if you have any problems related to your contact lenses, such as an eye infection, there would be no additional charges to be seen within the 90 day period.

Any questions regarding these policies should be addressed at the time of the contact lens fitting.
Level 1 Fit $45.00 Spherical fits

Level 2 Fit $55.00 Toric (astigmatism CL's), Monovision, Multifocal, Gas Perm Fits

*These fees are "in addition" to the eye exam fee of $59.00
Billing/Payment Information
We will not perform any "back billing" of my services to insurance providers with information provided at a later date. Also, if insurance information is NOT provided today, I will pay the full amount due for services rendered, and bill for the insurance reimbursement myself. Furthermore, if I am not using insurance today, I understand that payment is due today for the services received today.

I also agree to pay for any contact lens exam fees for services performed (fees listed above).
Name of Person Filling out Form
First Last
Patient Signature or Patient's Legal Representative

Level 1 Fit	$45.00	Spherical fits
Level 2 Fit	$55.00	Toric (astigmatism CL's), Monovision, Multifocal, Gas Perm Fits

Target Optical Patient Intake Form

Patient Intake Form

HIPAA notice and Insurance

Acknowledgement of Receipt of Privacy Notice

AUTHORIZATION FOR THE USE AND DISCLOSURE OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION

CONTACT LENS POLICIES

**If "yes" read contact lens policies below, if "no" then drop down to "Billing/Payment" section

Billing/Payment Information