New Patient Registration

Name*

First NameMiddle InitialLast Name
Email
example@example.com
Home Phone Number*
Please enter a valid phone number.
Mobile Number
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Are you self pay?*

YESNO
Are you the subscriber?*

YESNO
Name of Subscriber*
Primary Insurance Company*
ID Number*
Group Number
Please attach a photo of the FRONT side of your PRIMARY insurance card. You can use your cell phone to take the picture.

Cancelof
Please attach a photo of the BACK side of your PRIMARY insurance card. You can use your cell phone to take the picture.

Cancelof
Do you have secondary insurance?*

YESNO
Are you the subscriber?

YESNO
Name of Subscriber
Secondary Insurance Company
ID Number
Group Number
Please attach a photo of the FRONT side of your SECONDARY insurance card. You can use your cell phone to take the picture.

Cancelof
Please attach a photo of the BACK side of your SECONDARY insurance card. You can use your cell phone to take the picture.

Cancelof
Race

WhiteBlack/African AmericanAsian/ Pacific IslanderIndianAmerican IndianIndianOther
Ethnicity

HispanicNon-HispanicPrefer not to Report
Language

EnglishSpanishASLOther
Occupation
Marital Status
Live alone or with another person/people?
Emergency Contact Name *
Relationship to Emergency Contact*
Emergency Contact Phone Number*
Please enter a valid phone number.
Pharmacy Name
Pharmacy Phone Number
Please enter a valid phone number.
Primary Care Physician Name
PCP Phone Number
Please enter a valid phone number.
Referring Doctor Name *
N/A if not applicable.
Referring Doctor Phone #
Please enter a valid phone number.
Date of Last Visit with referring eye doctor

MonthDayYear
Date
Is the referring doctor your regular eye doctor?
If NO, who is your regular eye doctor?
Date of last visit with regular eye doctor

MonthDayYear
Date
Reason for your visit: (500 character limit)*

0/500
Date issue started

MonthDayYear
Location

Right EyeLeft EyeBoth Eyes
Severity

MildModerateSevere
Quality

BlurryFoggyDoubleOther
Do you wear glasses?

YESNO
If yes, how often do you wear them?
Do you wear contact lenses?

YESNO
If Yes, which type?

SoftHard
Date last worn

MonthDayYear
Date
Do you have difficulty with any of the following, even with glasses?:

DrivingWatching TVCraftsReadingComputer UseWritingRecreational ActivitiesOther
Do you drive?

YESNO
Do you drink alcohol?

YESNO
If yes, how often: Occasionally 1/day 2-3/day 4+/day
Do you use recreational drugs?

YESNO
Are you pregnant?

YESNO
Have you ever had a blood transfusion?

YESNO
Are you taking any medications?*

YESNO

Are you allergic to any medications?*

YESNO
If yes, list medication allergies:*
Do you use tobacco?*

YESNO
If yes, how many packs/cigarettes a day? Amount

PRIVACY AUTHORIZATION NOTICE
I have read the *Notice of Privacy Practices* and *Office and Financial Policy*
by signing this form consent to the use and disclosure of my protected health information. I have the right to review the Notice before signing this consent and I am aware that terms of the Notice may change.

I have read and agree*
May we call, email, or send a text to you to confirm appointments?

YESNO
May we leave a message on your answering machine at home or on your cell phone?

YESNO
Additionally, I authorize the release of information to the following person(s):

First Name Last Name
First NameLast Name
CONSENT FOR MEDICAL RECORDS MAINTENANCE

(sign in box with finger, stylus or if no touchscreen use mouse)
I have read the Eye Care of Delaware, LLC "Medical Records Maintenance Policy" (included in the Notice of Privacy Practices) and by signing this form consent to this arrangement.*

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EYE CARE OF DELAWARE, LLC OFFICE AND FINANCIAL POLICY

(sign in box with finger, stylus or if no touchscreen use mouse)
I have read the Eye Care of Delaware, LLC/Cataract and Laser Center, LLC "Office and Financial Policy" and by signing this form consent to the terms.*

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PATIENT AUTHORIZATION ASSIGNMENT OF MEDICARE/MEDICAID BENEFITS

(sign in box with finger, stylus or if no touchscreen use mouse)
I request that payment of authorized Medicare/Medicaid benefits be made on my behalf to any physician utilizing the Eye Care of Delaware and/or Cataract and Laser Center for any service furnished. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Service (CMS) and its agents any information needed to determine these benefits payable for related services. In Medicare/Medicaid assigned cases, the provider agrees to accept the charge determination of the Medicare/Medicaid carrier and I am responsible f or the deductible, co-insurance and/or the 20% Medicare does not pay, and for any non-covered services. My signature below further verifies that I have not joined an HMO or other entity in which my Medicare benefits have been relinquished.*

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COMMERCIAL/HMO/BLUE SHIELD/SECONDARY INSURANCE

(sign in box with finger, stylus or if no touchscreen use mouse)
I request that the payment of authorized benefits be made either by me or on my behalf to any physician utilizing the Eye Care of Delaware and/or Cataract and Laser Center, for services provided to me. I authorize any holder of medical information about me to release it to my insurer, or any information needed to determine these benefits payable for related services. I am responsible for any insurance deductible, co-insurance, non-covered services and exclusion of benefits. It is my responsibility to obtain any referrals required for services. If a referral was required and not obtained I will be responsible to pay for the services received. This assignment shall remain in effect until revoked by me in writing. A photocopy of this assignment is considered valid as the original.*

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REFRACTION POLICY
A refraction is a diagnostic test used to determine the refractive error (or focusing error) of your eyes. A refraction is often used to calculate your glasses or contact lens prescription. It is also necessary data for the evaluation of cataracts and/or secondary membranes. For healthy eyes, the best corrected vision is generally 20/20. Worse vision can indicate a medical problem (such as cataracts) or can be due to a simple refractive error (such as nearsightedness or astigmatism). Unfortunately, Medicare and most medical insurance plans do not cover the cost of the refraction. These plans consider the refraction a separate non-covered service and require that it be billed to the patient. The cost of the refraction is $45.00 and due at the time of service. If you wish to be billed for the refraction and pay at a later date, the cost will be $60.00.*

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PRIVACY AUTHORIZATION NOTICE

CONSENT FOR MEDICAL RECORDS MAINTENANCE

EYE CARE OF DELAWARE, LLC OFFICE AND FINANCIAL POLICY

PATIENT AUTHORIZATION ASSIGNMENT OF MEDICARE/MEDICAID BENEFITS

COMMERCIAL/HMO/BLUE SHIELD/SECONDARY INSURANCE

REFRACTION POLICY