• Lake Stevens Vision Clinic Intake Form (Returning patient)

  • PATIENT INFORMATION

  • Birthdate*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Did your address, phone, or email change*
  • Format: 000-000-0000.
  • Format: 000-000-0000.
  • Today
     / /
    2 digit month, 2 digit day, 4 digit year

  • BILLING INFORMATION

  • Lake Stevens Vision Clinic accepts both vision plans (Vision Service Plan, NBN) and medical insurances (Blue Cross/Blue Shield, Medicare, etc.) to help pay for your eye exam services and eye care products.


    VISION PLANS cover routine wellness eye exams and glasses and/or contact lenses. Vision plans do not cover medical eye exams for the diagnosis, management or treatment of eye health problems such as eye infections, dry eyes, cataracts, diabetes, glaucoma, and macular degeneration.

    MEDICAL INSURANCES must be used to help pay for medical eye exams.

    If you have both types of insurance plans, we will bill the appropriate services to the appropriate insurance plan. We will coordinate the benefits to help maximize your benefits and to minimize your out-of-pocket expenses. Please provide your insurance cards for our billers to provide accurate billing. Out-of-pocket costs are due at the time of service.

  • Did your billing information change?*
  • Primary Medical Insurance*

  • Policyholder birthdate*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Click here
    Cancelof
  • Click here
    Cancelof
  • Primary Vision Plan*
  • Policyholder birthdate*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Do you have any secondary vision plan or medical insurance?*
  • Policyholder birthdate*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Click here
    Cancelof
  • Click here
    Cancelof

  • HEALTH HISTORY

  • I wear*

  • Any problems with your current glasses?*
  • How often do you replace your contact lenses?*
  • Any problems with current contact lenses?*
  • Eye History (check all that apply)*

  • Any changes to your medical health since your last visit?*
  • Do you have any medical conditions?*
  • General

  • Genitourinary

  • Gastrointestinal

  • Psychiatric

  • Endocrine

  • Ear / Nose / Throat

  • Allergic / Immune

  • Integumentary

  • Cardiovascular

  • Muscular / Skeleton

  • Respiratory

  • Hematologic / Lymph

  • Neurological

  • Pregnant / Nursing*
  • Any changes to your medications since your last visit?*
  • Do you currently take any medications?*
  • Click here
    Cancelof
  • Do you have any allergies?*
  • Tobacco / Alcohol usage*

  • Family eye/medical history*

  • RETINAL WELLNESS IMAGING SCREENING

  • Our doctors recommend ALL patients, including children, to have a digital image of the retina annually. This screening is an important part of a thorough annual eye health evaluation and aids us in detecting early retinal disease such as macular degeneration, glaucoma, or diabetic retinopathy.

    The copay is $39. When applicable, retinal imaging will be billed to either your medical insurance or your vision plan, in which case the cost may be adjusted as required by insurance.

  • Please choose an option*

  • LIFETIME AUTHORIZATION

  • I request that payment of all medical benefits to be made on my behalf to Lake Stevens Vision Clinic, Inc. for all services and materials furnished to me by the Physicians at Lake Stevens Vision Clinic, Inc.

    I fully understand that I am obligated to pay any portion of the office fees that are not covered by my insurance company, including deductibles, co-pays or non-covered services.

    I fully understand that information obtained from my insurance carrier on my behalf, relating to medical or vision care benefits, by the staff at Lake Stevens Vision Clinic, Inc. is not a guarantee of payment or a guarantee of actual benefits to be paid or allowed by my insurance carrier.

    If, after 60 days of the initial insurance billing, all account balances owed by myself, any of my dependents, or any insurance carrier to the Lake Stevens Vision Clinic, Inc. have not been paid in full, for whatever reason, I agree to pay those past due amounts in full.

  • ACKOWLEDGEMENT OF NOTICE OF PRIVACY PRACTIES

  • I have seen a copy of the HIPAA Notice of Privacy Practices from Lake Stevens Vision Clinic. I am aware a copy can be provided by request, or viewed online at http://lsvc.com/forms.

  • RELEASE OF RECORDS & EMERGENCY CONTACT

  • Format: (000) 000-0000.

  • By signing and pressing submit, I acknowledge that I have read the entirety of this form and answered to the best of my knowledge.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
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