Patient Demographic Form
Personal Information
Today's Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Middle Name
Last Name
Suffix
Nickname
Name you prefer to be called while in our office
Date of Birth
*
-
Month
-
Day
Year
Sex
*
Male
Female
Marital Status
Married
Single
Widowed
Divorced
Domestic Partnership
Work Status
Full-Time
Part-Time
Contract
Student
Unemployed
Employer/School
Occupation
Race
*
Asian
Black or African American
Native American
Native Hawaiian or Pacific Islander
White
Other
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Preferred Language
*
Contact Information
Home Phone Number
*
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
Cell Phone Number
*
-
Area Code
Phone Number
May we text your cell phone to allow you to quickly confirm or reschedule upcoming appointments?
*
Yes
No
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Preferred Contact Method:
*
Telehone
Email
Postal
Guardian/Responsible Party Information
Is the patient a minor?
*
Yes
No
Guardian/Responsible Party Name
First Name
Last Name
Address is the same as patient:
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Relationship to patient
Emergency Contact
Name
*
First Name
Last Name
Relationship to Patient
*
Contact Phone Number
*
-
Area Code
Phone Number
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Privacy Policies and Consent Forms
Notice of Privacy Practices and HIPAA Agreements
I acknowledge that I received a copy of William H. Stephen, O.D. Notice of Privacy Practices.
Patient Authorization to Disclose Protected Health Information. HIPAA policy prevents our office sharing your protected heath information (PHI) with anyone other than yourself without your consent. If you would like someone other than yourself to have access to your health record, please include their name below.
Office Policies
I have read and understand the office policies of St. Lucy's Vision Center.
St. Lucy's Vision Center Finance Agreement
I authorize this office to release any information necessary to expedite insurance claims. I authorize use of signatures on this form for insurance claim submissions. I authorize payment directly to my doctor. I understand that I am responsible for all charges, regardless of insurance coverage. All accounts past 60 days are subject to 1 ½ % finance charge – annual rate 18%.
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Insurance Information
Vision Insurance
Though often provided in conjunction with medical health insurance plans, vision plans generally are managed through a separate insurance company (e.g Vision Service Plan, VSP, Eyemed). These plans provide discounts and benefits towards routine eye exams, glasses and contact lenses, but not for medical eye issues such as disease, infections or injuries. For most patients, the vision insurance company managing these benefits is not the same as their health insurance company.
Do you have vision insurance?
*
Yes
No
Insurance Company Name
Policy Holder's Name
First Name
Last Name
Policy Holder's Date of Birth
-
Month
-
Day
Year
Insurance Policy/ID Number
Insurance Group Number
Medical Insurance
Medical insurance can be used within our practice for the treatment and management of eye diseases, infections, injuries and other non-routine services. We encourage all our patients to provide this information even if you are scheduled only for your routine eye exam. Having this information on file will allow us to manage, treat, or refer to other providers for medical issues should any arise during your visit. Claims will never be sent to your medical insurance without your consent.
Do you have medical insurance
*
Yes
No
Policy Holder's Name
First Name
Last Name
Policy Holder's Date of Birth
-
Month
-
Day
Year
Insurance Company Name
Insurance Policy/ID Number
Insurance Group Number
Is this an HMO plan?
Yes, this is an HMO plan
No, this is a PPO plan
Unsure
Secondary Medical Insurance
Do you have a secondary medical insurance plan?
*
Yes
No
Policy Holder's Name
First Name
Last Name
Policy Holder's Date of Birth
-
Month
-
Day
Year
Insurance Company Name
Insurance Group Number
Insurance Policy/ID Number
Is this an HMO plan?
Yes, this is an HMO plan
No, this is a PPO plan
Unsure
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