Existing Patient Registration Form

Health History Questionnaire - Returning Patients

So much shorter than last time.
Name*

First NameMiddle NameLast Name
Contact Number*

Same as last timeI'd like to update my phone number
New Contact Number*

Area CodePhone Number
CellHomeWork
E-mail*

Same as last timeI'd like to update my email address
New E-mail*
Email
Address*

Same as last timeI'd like to update my address
New Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

If you do not see a green checkmark at the end of submission on the next page......we will not get your health history form.

Giant Green Checkmark = Good to go!!

NOTICE OF PATIENT PRIVACY RIGHTS, PROTECTION, AND RESPONSIBILITY
Financial Responsibility for Professional Services and Materials- I understand that payment for 100% of professional services rendered is due at the date of service. I will assume full financial responsibility for services rendered to me if my vision or medical insurance carrier denies or does not cover my claim for these services. This includes copays, coinsurance, and deductible for any services rendered that are determined to be “non-covered services” by my plan. Zen Eye Care cannot waive any copays or deductibles in agreement with my insurance contract. If I am not using vision or health insurance, Zen Eye Care offers a self-pay discounted fee schedule. I understand that payment for 100% of materials is due at the time materials are ordered. If I am supplying my own frame, I understand that many plastic and metal products may weaken over time and I will not hold Zen Eye Care or my insurance carrier responsible for accidental laboratory breakage. If I do not pick up my materials within 60 days from my initial order, my materials will be returned to the laboratory, and my initial deposit will not be refunded. If I am to receive contact lenses by mail, I understand that I am required to pay in full at the time materials are ordered. I acknowledge all of my Financial Responsibilities by signing the bottom of this page.Patient Satisfaction Guarantee applies to single vision and progressive lenses. We use only premium single vision optics and premium progressive addition lenses, otherwise known as no line bifocals. Less than one percent of our patients have difficulty adapting to our premium lenses. We will remake a non-adapt progressive lens or single vision lenses one time, in the same frame. If a progressive lens is still unsatisfactory, we will replace it with a lined bifocal or a single vision lens, in the same frame.*

I have read the financial responsibility practices
Notice of Privacy Practices- We keep a record of the health care services we provide to you. You may request a copy of your medical record in writing. We will not disclose your record to others unless you direct us to do so or unless legal authorities authorize or compel us to do so. You may request a copy of your medical record or get more information by contacting a Zen Eye Care officer. Our Notice of Privacy Practices is available at the reception desk. The Notice describes in greater detail how your health information may be used or disclosed, and how you can access your information. You are entitled to a copy of this Notice and it is available at your request. I acknowledge the Notice of Privacy Practices has been offered to me and is readily available in accordance with the Health Insurance Portability and Accountability Act (HIPAA).*

I have read the HIPAA privacy practices
Telemedicine Practices- The laws that protect the privacy and confidentiality of medical information also apply to telemedicine. No information obtained during a telemedicine encounter which identifies me will be disclosed to researchers or other entities without my consent. I have the right to withhold or withdraw my consent to the use of telemedicine during the course of my care at any time. I understand that my withdrawal of consent will not affect any future care or treatment, nor will it subject me to the risk of loss or withdrawal of any health benefits to which I am otherwise entitled. I have the right to inspect all information obtained and recorded during the course of a telemedicine interaction and may receive copies of this information for a reasonable fee. A variety of alternative methods of medical care may be available to me, and I may choose one or more of these at any time. My physician has explained the alternative care methods to my satisfaction. Telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out-of-state. I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured. My condition may not be cured or improved, and in some cases, may get worse. I understand that billing will occur by my doctor and, in the case of an electronic consultation, can from an additional doctor. *

I have read the Telemedicine practices
New Prescription Law - Eye doctors must now obtain confirmation that a patient received their eyeglasses prescription and, in cases where the prescription is provided electronically, doctors must obtain consent to send the prescription electronically (via Email or portal). Zen prefers this method as we like to be stewards of the environment and reduce unnecessary usage of resources.*

I am fine receiving my prescriptions electronically
Signature of Patient/ Responsible Party*

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Health History Questionnaire - Returning Patients