Global Eyecare Optometry Patient Form

Please select office location of your eye appointment*

Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

MonthDayYear

Sex

Marital Status

Best Contact Number*

Cell Phone NumberHome Phone Number

E-mail*

Employer

Occupation

In case of emergency...

Emergency Contact:*

First NameLast Name

Relationship to Patient*

Contact Number*

PRIMARY Insurance Policy Holder

First NameLast Name

Date of Birth of PRIMARY Insurance Policy Holder

MonthDayYear

Social Security Number of PRIMARY Insurance Policy Holder (Full SSN or last 4 SSN)

Full Social Security Number or last 4 Digits

Relationship to Patient

What is the name of your insurance for MEDICAL and VISION?

Please attach a copy of both sides of your insurance card

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Financially Responsible Party Name

First NameLast Name

Financially Responsible Phone Number

I understand and acknowlege the following:

This office will act as my agent in obtaining payment from my insurance company. However, I understand that I am ultimately responsible for my bill. I am financially responsible for all copays, deductibles and coinsurance amounts.
I authorize Global Eyecare Optometry to bill my insurance company and receive payments.
I authorize Global Eyecare Optometry to release any information needed for the processing of my claim.
I understand that payment for all optometric professional services is due at the time of service. Contact lens exams require an additional evaluation/fitting fee.
I understand that payment for eye glasses and contact lenses is due at the time of ordering.
I agree to the Privacy Policy and understand the information below refers to my rights under the Health Insurance Portability and Accessibility Act (HIPAA):
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your demographic information, that may identify you and that relates to your past, present or future physical and mental health or condition and related health care services.

Uses and Disclosure of Protected Health Information. Your PHI may be used and disclosed by your physician, our office staff and others outside our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law.

Treatment. We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination and management of your health care with a third party. For example, we would disclose your PHI, as necessary, to a home health agency that provides care to you. For example, your PHI may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment. Your PHI will be used, as needed, to obtain payment for your health care services. For example, obtaining approval of a hospital stay may require that your relevant PHI be disclosed to the health plan to obtain approval for the hospital admission.

Health Care Operations. We may use or disclose, as needed, your PHI in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conduction or arranging for other business activities. For example, we may disclose your PHI to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We may use or disclose your PHI without your authorization in these situations: as required by law, public health issues as required by law, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, worker's compensation, inmates, required uses and disclosures. Under the law, we must make disclosure to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500. Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law.

Signature*

Please check any of the conditions you have:*

Please describe allergies (seasonal, medications)

Please check any of the below that apply:

Do you smoke?Do you drink?Do you use a illegal substances?None of the above

Please list any medication that you are currently taking or enter NONE:*

If No Medications, Please Enter None

Please check any of the eye conditions you have:*

Please check any medical and eye conditions your family members have:

If so, please specify whom.

Are you interested in ordering new glasses?*

YesNoMaybe

If Yes, please describe frame styles or brands interested. (e.g. plastic, metal, titanium, round, rectangular, RayBan etc)

Do you need to order more contact lenses?*

YesNoI don't wear contact lenses

Are you interested in myopia control methods such as Ortho-K/CRT or Atropine? Interested in vision correction to 20/20 without surgery, glasses or contact lenses?*

YesNoMaybe

Who may we thank for referring you? Please enter a Name, "walk-in" or "online"*

To respect your appointment time and other scheduled patients our office has the following policies in place:

One "No Show" will be allowed without penalty (life happens, we understand)

After One "No Show", we will require a credit card on file to schedule an appointment and you will be charged a $50 fee for all subsequent "No-Shows" (as defined below):

An appointment is considered a "No Show" if:

It is cancelled or rescheduled less than 48 hours before the scheduled time
You arrive more than 15 minutes late to your scheduled appointment
The appointment is missed entirely

These policies will allow us to give each patient our undivided attention and the best experience possible.

Thank you for your understanding.

Patient Signature*

Date

Welcome to Global Eyecare Optometry

Patient Registration

Insurance Information and Release

Please Complete For Minors

Acknowledgement

Health History

Medications

Ocular Health History

Missed and Late Appointment Policies