• Welcome Back Form

  • Welcome Back!Thank you for taking the time to fill out this form to make sure our records are up to date!

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    Preferred Pronouns:                          

  • Date of birth:   Pick a Date   SSN(if applicable):      

  • EMERGENCY CONTACT
          Relationship:     
     Phone:         

  • PRIMARY CARE PROVIDER
     Name: *   Clinic:     
     Phone:         

  • MEDICATION CHANGES(if applicable)
       

  • VISION INSURANCE (if applicable)
    Insurance Company:      ID:#      
    Primary Insured:         Date of birth:   Pick a Date
    Relationship to Insured:      

  • MEDICAL INSURANCE (if applicable)      
    Insurance Company:   *  If other please specify,    *ID:#   *      

    Primary Insured:         Date of birth:   Pick a Date
    Relationship to Insured:      

  • I have provided any and all insurance information. If any is withheld at time of service, I acknowledge I am responsible for the usual and customary charges for services rendered.

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  • I have read and agree to the Office Policies agreement set by Griswold Eye Care, PLLC.

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  • HIPAA POLICY: Please read carefully. Signature Required.I agree to allow my medical information be shared with my insurance company for the sole purpose of billing and to any healthcare provider necessary for continuity of care. I acknowledge that I am aware that Griswold Eye Care has a notice of privacy practicesavailable to me at all times during normal business hours. I fully understand that I am protected under HIPAA and will be required to sign a release for any and all medical records.

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    Insurance Billing Acknowledgment

     

    Vision plans like VSP cover routine eye exams and refractive conditions such as nearsightedness, farsightedness, astigmatism, and presbyopia.

    If the doctor identifies a medical eye condition (including but not limited to dry eye, glaucoma, macular degeneration, cataracts, infections, retinal conditions) or signs of a systemic medical condition affecting the eyes (such as diabetes, hypertension, autoimmune or thyroid disease), your visit must be billed to your medical insurance.

    Because this determination can only be made after the doctor performs the examination, we cannot know in advance which insurance will apply.

    I understand that if a medical condition is diagnosed, my medical insurance will be billed and I am responsible for any applicable copays, deductibles, coinsurance, or non-covered services.

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