EMERGENCY CONTACT INFORMATION
RESPONSIBLE PARTY (INSURANCE)
VISUAL AND MEDICAL HISTORY
FAMILY MEDICAL HISTORY
Please select relationship to any medical history or none for every option.
REVIEW OF SYSTEMS
Do you currently, or have you ever had any issues in the following areas: (Check the box if your answer is yes )
(This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.)
____ Yes, I prefer to discuss my Social History with the doctor.
I, the patient/guardian/responsible party, have accurately and truthfully completed the information listed on this form. I agree that all fees incurred are my responsibility regardless of insurance coverage. I acknowledge that I have received a “Notice of Privacy Practices” regarding the use and disclosure of my health information. (Form is available at the front desk.)
ACKNOWLEDGEMENTOF NOTICE OF PRIVACY PRACTICES
If you are signing as a personal representative of the patient, please indicate your relationship.
I give permission to Corridor Family Eyecare to discuss my health care needs with if I am unable to speak with them personally.
Vision vs. Medical Insurance
Most people have both vision and medical insurance. They are very different in the terms of the services they cover and it’s important to understand those differences. Vision coverage is mainly designed to determine a prescription for glasses, help pay for glasses or contacts, and to screen for medical conditions. It is not designed to be used for medical conditions, diagnostic or screening tests, or treatment plans. Some medical plans have a vision benefit.
When a medical diagnosis or condition is present (such as diabetes, high blood pressure, etc.) or an eye disease (such as infections, dry eye, allergies, cataracts, etc.) it is necessary to file the claim for your visit toyour medical plan, and the co-pays, co-insurance, non-covered services, and deductibles apply. Visioninsurance does not cover medical eye problems. Our office does not make the rules; they are defined by insurance carriers and we are required to follow them.
In most cases, it is difficult to know prior to examination which type of insurance will apply or with whom our office will be able to file a claim for you. We make every effort to determine as much information for you in advance.
I understand the paragraphs above and authorize Corridor Family Eyecare to file a claim on my behalf and I understand that I am responsible for any co-pays, co-insurance, or deductible not yet met.
Corridor Family Eyecare Robert T. Kingus O.D.5350 Kirkwood Blvd. SW Suite 100, Cedar Rapids, IA 52404 Tel: 319-365-2946 Fax:319-365-2948www.corridorfamilyeyecare.com firstname.lastname@example.org