familyeyecarelabelle - New Patient Form

100 N Main Street
LaBelle FL 33935
(863) 675-0761
Information Regarding Dilating Eye Drops and Refraction
Patient Full Name

First NameLast Name
Dilating drops are used to dilate or enlarge the pupils of the eye to allow the optometrist to get a better view of the inside of your eye.

Dilating drops frequently blur vision for a length of time which varies from person to person and may make bright lights bothersome. It is not possible for your optometrist to predict how much your vision will be affected. Because driving maybe difficult immediately after an examination, it is best if you make arrangements not to drive yourself.

Adverse reaction, such as acute angle-closure glaucoma, may be triggered from the dilating drops. This is extremely rare and treatable with immediate medical attention.

I hereby authorize Dr. Parrish and/or Dr. Youmans or their assistants as may be designated by him/her to administer dilating eye drops. The eye drops are necessary to diagnose my condition.

Refraction NON COVERED SERVICES

Medicare and most other insurance companies do not pay for the refraction part of the eye exam. If a refraction (part of exam that determines "your need for glasses) is necessary during the exam, the insurance company will disallow it, stating it is not a covered benefit. Therefore, the patient will be responsible for the refraction charge.
Patient Signature (or Authorized Person) *

Clear
Date

MonthDayYear
Patient Signature (or Authorized Person) *
Lifetime Signature*
Witness
Date

MonthDayYear

LIFETIME CONSENT FOR RELEASE OF HEALTH INFORMATION
FOR TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS
AND FINANCIAL POLICY STATEMENT (Rev 09232013)
Financial Policy

Payment for services is requested at the time services are rendered. For materials, ordered, we ask for full payment at the time of ordering. If our policies pose a financial burden, please ask to speak with the Office Manager on Accounts Coordinator.

I understand that my insurance contract is between my insurance company and me. It is the responsibility of the patient to know and understand their medical insurance benefits. If my insurance has not paid my claim within 60 days for the date insurance was billed, I will be responsible for payment. I also agree that I am responsible for any charges that my insurance company will not cover. I understand that failure to pay my account or make suitable financial arrangements may result in my account being placed in a state of delinquency. If this becomes necessary, I agree to pay all collection fees, which include but are not limited to collection fees, court fees, attorney fees and any other fees for the collection of my account balance. I also understand that is I write a check that is returned for any reason, I will be charged a fee according to Florida Statute.

COMMERCIAL INSURANCE:

Family Eye Care will bill insurance provided we are a member of the network your company is involved with. We will verify the insurance coverage and let you know what, if any, percentage you will be responsible to pay. Payment is due on the date of service.

I request that payment of authorized benefits be made on my behalf to Family Eye Care for any services furnished. I authorize and consent to any holder of medical or other information including the results of any HIV (human immunodeficiency virus) tests about me, to release to the health care financing administration, its agents, or other insurance company as noted any information needed to determine these benefits payable for related services
Lifetime Patient Signature*
Signature

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Date

MonthDayYear
Assurance of Medicare Compliance

Healthcare fraud and abuse have been identified as a national problem, costing taxpayers literally billions of dollars each year. We want you to know that all our employees, managers and doctors continually undergotraining so that they may understand and comply with government rules and regulations regarding Medicare. We strive to achieve the very highest standards of ethics and integrity in performing services for our Medicare patients. It is our policy to properly determine accurate compensation for our services in accordance with the governmental rules, laws, and regulations. We want to ensure that our practice never contributes in any way to the growing problem of improper Medicare expenditures. As part of this plan, we have implemented a Compliance Program that we believe will help us prevent any Medicare service or billing errors. We also know that we are not perfect! Because of this fact, our policy is to listen to our employees and our patients without any thought of penalization if they feel that an event in any way compromises our policy of integrity. More so, we welcome your input regarding any billing or service problem so that we may remedy the situation promptly.

MEDICARE PART B / COMMERCIAL INSURANCE SIGNATURE ON FILE:

Family Eye Care will accept assignment from Medicare. You are responsible for the 20% co-payment on the date of service, any deductible that has not been met and any non-covered services and diagnoses, i.e. refraction, farsightedness, nearsightedness, etc.

If you have a Medicare supplement, we will file a claim with them provided they will make payment directly to our office.

I request that payment of authorized Medicare benefits or any other insurance company be made on my behalf to Family Eye Care for any services furnished. I authorize and consent to any holder of medical or other information including the results of any HIV (human immunodeficiency virus) tests about me, to release to the health care financing administration, its agents, or other insurance company as noted any information needed to determine these benefits payable for related services.
Lifetime Patient Signature*
Date

MonthDayYear
Signature

Clear

LIFETIME CONSENT FOR RELEASE OF HEALTH INFORMATION
FOR TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS
AND FINANCIAL POLICY STATEMENT
REFRACTION – NON COVERED SERVICES:

Medicare and most other insurance companies do not pay for the refractive part of any eye exam. If a refraction (part of exam that determines your need for glasses) is necessary during the exam, the insurance company will disallow it, stating it is not a covered benefit. Therefore, the patient will be responsible for the refraction charge.
Patient Signature*
Signature

Clear
Date

MonthDayYear
OUTSIDE LAB TESTING:

Occasionally, our doctors deem it necessary for lab work to be done. I understand this will be done by an outside agency and I will be responsible for payment to that agency for lab work done.
Please initial that you have read and understand this
Return Policy

Professional Services

Fees for professional services are non-refundable.

Glasses/Ophthalmic Products

Glasses are complex, custom-made medical devices comprised of a set of frames and spectacle lenses. In the event that a patient is not completely satisfied with the visual acuity obtained with the prescription lenses provided by Family Eye Care, the patient will be asked to return to the office for an adjustment of the glasses and, as necessary, to schedule a short prescription re-evaluation with the doctor. Family Eye Care makes every effort to provide glasses that are accurate to the prescribing doctor’s instructions.

This process must be initiated within 90 days of the original purchase date. Returns and refunds are considered by the office management on a case-by-case basis. Restocking fees may apply.

Professional Services

In the case of a prescription change for contact lenses, you may return or exchange unused contact lenses purchased from Family Eye Care within one year of the original purchase date. Merchandise must be in the original, unopened packaging. All merchandise must be in like-new condition.

By typing your name in the space provided below, means acceptance and agreement with the above policies.
Full name
Signature*
Date

MonthDayYear
Do we have your permission to obtain medication history through the pharmacy/medical network?

YesNo
Do we have your permission to talk to family members or other individuals about you?

YesNo

If so, please list the name and relationship to you:

	Name	Relationship
1
2
3
4
5

VERY IMPORTANT!!!!

We have started collecting email addresses and /or cell phone numbers to use for confirming appointments, appointment reminders and other electronic communication via a third party. Please acknowledge by signing below and entering your email address and cell phone number to show your authorization to be contacted by email and/or text.
Email Address *
Cell Phone*
Date*

MonthDayYear
Lifetime Patient Name*
Authorization*

I consent to receive electronic communication from Family Eye Care
Signature to authorize electronic communication*

Clear
CONSENT TO USE OR DISCLOSE HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
Patient Name

First NameLast Name
Date

MonthDayYear
In the course of providing service to you, we create, receive, and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services, and to conduct health care operations involving our office.

We have a comprehensive Notice of Privacy Practices that describes these uses and disclosures in detail. You are free to refer to this Notice at any time before you sign this consent document. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and services provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes submission of your health information to third-party payers or insurers for claims review, determination of benefits and payment; our submission of your health information to auditors hired by third-party payers and insurers, among other aspects of payment described in our Notice of Privacy Practices. Our Notice of Privacy Practices will be updated whenever our privacy practices change. You can get an updated copy here at the office.

When you sign this consent document, you signify that you authorize us to use and disclose your health information to treat you, to obtain payment for our services, and to perform health care operations. You can revoke this consent in writing at any time, unless we have already treated you, sought payment for our services, or performed health care operations in reliance upon our ability to use or disclose your health information in accordance with this consent. We can decline to serve you if you elect not to sign this consent form. You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment or health care operations, but as described in our Notice of Privacy Practices, we are not obligated to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.

I HAVE READ THIS CONSENT AND UNDERSTAND IT. I CONSENT TO THE USE AND DISCLOSURE OF MY HEALTH INFORMATION FOR PURPOSES OF TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS.

By typing your name in the space provided below, means acceptance and agreement with the above policies.
Type Full name
Signature*
Date

MonthDayYear
If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form:
Name
Relationship to patient
Source of authority

LIFETIME CONSENT FOR RELEASE OF HEALTH INFORMATION
FOR TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I,*
have received a copy of this office’s Notice of Privacy Practices on
MonthDayYear
Please Print Name
Signature*
Should be Empty:

	You	Family Member	Relationship
Amblyopia (Lazy Eye)
Blindness
Cataract
Color Blindness
Corneal Disease
Glaucoma
Macular Degeneration
Retinal Detachment
Retinal Disease
Strabismus (Eye Turn)

	Eyedrops/eye ointments	Dosages	Frequency	Take For
1
2
3
4
5

	You	Family Member	Relation
Allergic/Immunologic
Allergies/Hay Fever
Anemia
Asthma
Chronic Bronchitis
Chronic Cough
Constipation
Diabetes
Diarrhea
Muscle Pain
Post-Nasal Drip
Psychiatric
Rheumatoid Arthritis
Runny Nose
Seizures
Dry Throat/Mouth
Emphysema
Fever
Headaches
Heart Disease
High Blood Pressure
Joint Pain
Kidney/Bladder
Migraines
Sinus Congestion
Skin Problems
Thyroid/Other Glands
Vascular Disease
Weight Loss/Gain

	Medications	Dosages	Frequency	Why you take
1
2
3
4
5
6

New Patient/Financial Form

Emergency Contact

Responsible Party Information

Primary Medical Insurance

Secondary Medical Insurance

If you would like us to send information about our office to someone you know, please give us their information below.

New Patient Health Hx Form

Do you have or have a family history of any of the following?

Do you currently, or have you or any family member ever had any problems in the following areas?

Information Regarding Dilating Eye Drops and Refraction

Financial Policy

COMMERCIAL INSURANCE:

Assurance of Medicare Compliance

MEDICARE PART B / COMMERCIAL INSURANCE SIGNATURE ON FILE:

REFRACTION – NON COVERED SERVICES:

OUTSIDE LAB TESTING:

VERY IMPORTANT!!!!

CONSENT TO USE OR DISCLOSE HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES