New Patient Form

You keep your germs, and we'll keep ours! And we will be more environmentally friendly!

Paperwork can now be completed and signed on your own device. Of course, paper copies are available if you prefer.
Legal Name *

First Name Last Name
Preferred Name (If Applicable)
Phone Number *
Please enter a valid phone number.
Is it ok to text you appointment and/or eyewear reminders?

Yes No
Is it ok to leave you a voice message?

Yes No
Email (This will be used to set up your electronic health record (EHR) portal) *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth *

Month Day Year
Date
SSN (Last 4 is usually adequate for most insurance carriers)
Emergency Contact Name

First Name Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Occupation/Student Status
Marital Status
Race & Ethnicity
Gender *
Guardian (If Applicable)

First Name Last Name
Name of Primary Care Provider
How did you hear about us?
Please take a photo of the front of your driver's license or legal ID
Vision Plan Name (Common ones: EyeMed, VSP, Spectera/UHC)
Vision Plan ID Number
Medical Insurance Carrier
Please take a photo of the front of your medical insurance card
Please take a photo of the back of your medical insurance card
Patient Relationship to Primary Policy Holder

Self Spouse Child Other
Primary Policy Holder Name (If not the patient)

First Name Last Name
Primary Policy Holder Date of Birth (If not the patient)

Month Day Year
Date
Primary Policy Holder SSN (If not the patient)
Primary Policy Holder Address (If different from the patient)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Authorization to Release Information & Personal Responsibility for Payment
I hereby assign pertinent medical and/or surgical benefits (to which I am entitled) to the doctor caring for me. This includes major medical benefits, Medicare, Medicaid, private insurance, and any health and/or vision plans in which I am enrolled. This assignment will remain in effect until revoked for me in writing. I understand that I am financially responsible for all charges whether or not they are paid by insurance. I hereby authorize the holder of my medical and patient registration records to release any information needed to process insurance claims submitted on my behalf. *

Clear
Notice of Privacy Practices (NPP)/HIPAA

I understand that ModernEYES Eyecare + Eyewear (referred to below as “This Practice”) will use & disclose health information about me.

I understand that my health information may include both created and received by the practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments procedures, prescriptions and similar types of health-related information.

I understand and agree that This Practice may use and disclose my health information in order to:
- Make decisions about my plan for my care and treatment
- Refer to, consult with, coordinate among, and manage, along with other healthcare providers for my care and treatment
- Determine my eligibility for health plan or insurance coverage, and submit bill, claims and other related information to insurance companies or others who may be responsible to pay for some, or all, of my health care.
- Perform various office, administrative, and business functions that support my physician’s efforts to provide me with, arrange, and be reimbursed for quality, cost-effective healthcare.
I also understand that I have the right to receive and review a written description of how This Practice will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made, and the information practices followed by the employees, staff, and other office personnel of This Practice, and my rights regarding my health information.

I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any Notice of Privacy Practices. I also understand that a copy or summary of the most current version of This Practice’s Notice of Privacy Practices in effect will be posted in waiting/ reception area. I understand that I have a right to ask that some, or all, of my health information may not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests.

By signing below, I agree that I have reviewed and understand the information above, and that I have received a copy of the Notice of Privacy Practices upon request.
HIPAA Acknowledgement & Consent *

Clear
Relationship to Patient

Medical Insurance vs Vision Plans

Eye exams can be classified as two different types of exams: routine and medical. The differences in the exams dictate what insurance plan we bill, so we need to know what medical insurance and vision plans you may have.

Vision Benefit: This is a routine exam that addresses a glasses and/or contact lens prescription along with assessing the overall health of the eye. If eye health problems are noted, a follow up exam would be scheduled and your medical insurance would be billed.

Medical Insurance: This is an office visit for such conditions as glaucoma, diabetes, macular degeneration, dry eye, or red eye/injury. Most complaints of pain, redness, swelling, itching, and loss of vision are related to eye health and would most likely be diagnosed as medical.

Some offices may have utilized your Vision Benefit for both routine & medical eye care at your yearly exam. Due to the ever-changing landscape of healthcare, we are forced to split your eyecare into the two designations above. We apologize for any inconvenience this may cause, but are unwilling to compromise the integrity & excellence this office strives to provide. Thank you for your cooperation.
Contact Lens Fitting and Assessments
Would you like to have a contact lens fitting and assessment today? *

Yes. I currently wear or have worn contacts in the past. I acknowledge that my prescription will be available on the EHR portal once finalized. Yes. I will be a NEW WEARER of contact lenses. I acknowledge that my prescription will be available on the EHR portal once finalized. No

Contact Lens Policy

Current contact lens technology offers successful contact lens wear to most of our patients. Because contact lenses are medical devices placed on the eyes, they require expert fitting and careful instruction, as well as conscientious care and compliance with recommended follow‐up examinations to maintain the healthy function of your eyes. A complete ocular examination is necessary to evaluate for contact lens wear. Insertion and removal training will be provided if required. Follow up appointments are included for up to 90 days post-fit; any appointments related to your contact lenses may require additional payment. Payment for CL fittings are due at time of fitting. If changing type of fit, the difference will be charged at time of change. Specialty lenses such as custom lenses, scleral lenses and hybrid lenses may require deposit prior to ordering. Yearly examinations are required to maintain an active prescription.

Contact Lens Material Policy
- Materials purchased directly from ModernEyes Eyecare & Eyewear, PC will be serviced directly by ModernEyes Eyecare & Eyewear, PC. This includes ripped lens replacement, lost lens, extra trials at our discretion, etc.
- ModernEyes Eyecare & Eyewear, PC is unable to service lenses purchased from external vendors.
- Materials may be returned within 90 days, in unopened, new, sellable condition and the rebate has not been redeemed. Condition will be determined by ModernEyes Eyecare & Eyewear at time of return.
Prescriptions are available online in your patient portal once finalized. We will provide a printed copy of your prescription upon request. Please note that due to HIPAA compliance issues, we are unable to text or email your prescription.

Contact lenses may be ordered through ModernEyes in store, over the phone, on our website, or via LensFerry. Thank you for supporting our local, family-owned small business and purchasing your lenses from our office!
Contact Lens Policy Signature *

Clear

Advanced Technology Screenings

Fundus Evaluation: All ages

Comprehensive exams include fundus (retinal) evaluation and are an important part of your eyecare, as it allows the doctor to see the entire retina to check for holes, tears, detachments, as well as signs of diseases such as diabetes or tumors in the eye. There are two main ways to evaluate the health of the inside of the eye:
1. The preferred method is to use the Optos, which obtains a near full-field image of the internal eye. We review the images and can use the viewing software to measure and notate any abnormal findings. There are no side effects with utilizing the retinal camera to evaluate the internal eye health.
2. The second method is to use dilation drops to enlarge the pupils to allow for better viewing of the inside of the eye. The drops used to dilate the eyes will cause blurred vision (usually worse reading than distance) & light sensitivity for several hours. We do not charge extra for routine pupil dilation. From time to time, we may have to perform a stronger dilation, but will discuss with you if the need arises.
Optomap Video
Fundus/Retinal Evaluation (All Ages)

Yes, I agree to have Optos retinal photos. I understand I will be charged $39 (non-bundled) for this service unless it is covered by my Vision Benefit. I also understand that if the doctor sees something concerning on the photos, pupil dilation may be required for additional evaluation. I would prefer to have my pupils dilated
Women opting for dilation of pupils only:

I'm currently pregnant I'm currently nursing/pumping
Optical Coherence Tomography (OCT)

Typically for 16 years old and over

OCT is a non-invasive diagnostic instrument similar to an MRI scan that is used to allow doctors to see a 3D image of the retina and detect problems in the eye prior to any presence of symptoms. OCTs are commonly used to detect the top three diseases known to cause blindness: macular degeneration, glaucoma, and diabetic retinopathy, among other problems. When used as a screening tool, we obtain images of both the optic nerve and macula of each eye.
Optical Coherence Tomography (OCT): Typically for 16 years old and over

Yes, I agree to have a screening OCT performed today. I understand I will be charged $39 (non-bundled) for this service. Special Savings: I am opting for both the Optos and OCT technology bundle and will be charged $60 total for these services. I would like to talk to the doctor about this option
Should be Empty:

You keep your germs, and we'll keep ours! And we will be more environmentally friendly!

Authorization to Release Information & Personal Responsibility for Payment

Notice of Privacy Practices (NPP)/HIPAA

Medical Insurance vs Vision Plans

Contact Lens Fitting and Assessments

Contact Lens Policy

Contact Lens Material Policy

Advanced Technology Screenings

Fundus Evaluation: All ages

Optical Coherence Tomography (OCT)

Typically for 16 years old and over