Village Eyecare Patient Registration

  • Village Eyecare

    Patient Registration Form
  • Date Format: MM slash DD slash YYYY
    (m/d/y)
  • Date Format: MM slash DD slash YYYY
    (m/d/y)
  • Insurance Information

  • (m/d/y)
  • (m/d/y)
  • Emergency Contact

  • Financial Policy

    Thank you for choosing Village Eyecare for your eye care needs. We are happy to serve you, and look forward to a long relationship with you, our valued patient. In an effort to serve you efficiently, we have instituted the following financial policy. This policy outlines the understanding between you, the patient, and our office. Our office will, as a courtesy, file insurance claims based upon information you have provided us if we are a participating provider in your insurance plan. It is your responsibility to provie us with complete and accurate information. furthermore, if your insurance company requests more information from you, you must provide that information promptly. By signing below, you understand that you will be responsible for payment of any services no paid by your insurance company which includes co-payments, deductibles, coinsurance, and non-covered items, and denied services not covered by contract between our office and your insurer. If your claim is denied, it becomes your responsibility to pay the retail cost of those services and/or product. We will assist you in any way possible to be sure that the claim is handled properly, we will file our insurance claim for you and send a remainder statement when there is a balance to be paid by you. In some cases where deemed necessary, we reserve the right to refer uncollected balances to an outside collection agency. By keeping lines of communication open and providing accurate information, you can be sure that your claims will be handled promptly and efficiently. I understand that all accounts are full responsibility of the patient and/or the patient's responsible party/guarantor. In case of default payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to effect collection to this account or future outstanding accounts.
  • Date Format: MM slash DD slash YYYY

Village Eyecare Ocular History

  • Village Eyecare

    Patient Ocular History Form (Please answer the following questions to the best of your ability. They will help us provide you with a more thorough eye examination.)
  • Date Format: MM slash DD slash YYYY
  • Ocular History

  • Eyewear History

  • Contact Lens History

Village Eyecare Medical History

  • Village Eyecare

    Patient Medical History Form
  • Have you or any of your immediate family had or have any of the following conditions? (please check all that apply)

  • Yourself

  • Your family

Village Eyecare Privacy Practice

  • Village Eyecare

    Notice of Privacy Practice
  • Date Format: MM slash DD slash YYYY
  • I have read and reviewed this practice's Notice of Privacy Practice. The notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, and the practice's legal duties with respect to my protected health information. I understand that this practice reserves the right to change the terms of it's Notice of Privacy Practice and to make new provisions effective for all protected health information that it maintains. I understand that I can obtain this practice's current Notice of Privacy Practice on request.
  • Date Format: MM slash DD slash YYYY
  • (if signed by a personal representative of patient)