New Patient Registration

PATIENT INFORMATION:
Salutation
First Name*
MI
Last Name*
Preferred Name/Nickname
Date of Birth*
MM
DD
YYYY
Social Security #*
DL #
Address*
Street Address City State ZIP Code
Home Phone*
Cell Phone
Work Phone
Email*
How do you prefer to be contacted?*
Which location is your appointment?*
Marital Status?
Patient Employer / School*
Occupation*
How did you hear about our office?*
Referred by*
Please enter your race*

Are you the patient or responsible party for a minor?*
RESPONSIBLE PARTY:
Name of Responsible Party (if minor)*
First Last
Relationship to Patient*
Date of Birth*
Social Security #*
Address (if different)
Street Address City State ZIP Code
Phone (if different)
Name of Employer
Business Phone

Do you have vision insurance?*
Do you have medical insurance?*
VISION INSURANCE:
Vision Insurance Carrier*
Vision Insurance Policy #*
Vision Insurance Subscriber Name*
Policy Holder Date of Birth*
Policy Holder Social Security #*
MEDICAL INSURANCE:
Medical Insurance Carrier*
Medical Insurance Policy #*
Medical Insurance Subscriber Name*
Medical Insurance Subscriber Date of Birth*
Medical Insurance Subscriber Social Security #*

Doctor Recommendations for Your Visit
Retinal Photos*
Digital images of your eyes help assess the health of your retina to detect eye and health conditions such as glaucoma, diabetes and macular degeneration. Early detection is critical to potentially preventing serious disease progression and even vision loss. Images, compared side-by-side, year after year, discover even subtle changes and help to monitor your health. This cost of this screening is $34.00 for both eyes.
- Accept
- Decline
OCT (not available at Raytown, MO location)*
This scan of your retina allows us to detect early signs of ocular conditions including macular degeneration and glaucoma, which can significantly decrease the chance of your eyesight being permanently affected. It can also help us monitor changes due to high blood pressure, diabetes, corneal disorders and determine the cause of floaters. Generally, the OCT and the retinal photos are sold in combination to produce a comprehensive evaluation of the retina, macula, and optic nerve. The total cost for both OCT and Retinal Photos is $50.00.
- Accept
- Decline
- N/A
Dilation*
In order to perform a complete exam of the retina and the back of the eye, your optometrist strongly recommends the use of dilation. This may reveal the presence of a serious systemic condition as well as other ocular conditions. Dilation changes near vision for a short time, which varies from person to person and may make bright lights bothersome. This is included in your routine eye coverage at no additional charge.
- Accept
- Decline

Certification and Assignment
Please read and check to agree*
- To the best of my knowledge, the information submitted in this form is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my child, ever have a change in health. I certify that I, and/ or my dependent(s), have insurance coverage or otherwise billable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
NOTICE OF PRIVACY PRACTICE
THIS NOTICE DESCRIBE HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISLCOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We are required by law to maintain the privacy of your health information, to follow the terms of this notice, and to provide you with the notice of is legal duties and privacy practices with respect to your health information. We will not use or disclose medical information about you without your written authorization, except as described in this notice. How We May Use or Disclose Your Health Information We will protect the privacy of your health information. The law permits us to use or disclose your health information for the following purpose: Treatment, Payment, and Regular Health Care Operation - Information obtained by us will be used to dispense and provide prescription ophthalmic goods and services to you, bill your insurance carrier if you have third party coverage, and to record and monitor the service provided to you. Information will also be provided to you upon your request. As and When required by law- We may use and disclose your health information to Public Health Officials, Law Enforcement, Health Oversight Activities (for audits, investigations, etc.), Judicial and Administrative, Deceased Person Information., Worker Compensations programs, Food & Drug Administration (FDA for reporting of adverse drug events and quality issues), if there is a serious threat to your health or safety, in times of National Security, if you are in the military or a veteran of the armed forces when requested, of if you become an inmate in a correctional facility. Personal Communication- We may contact you to provide appointments reminders, annual eye examination cards, and other information about treatments alternatives or other health-related benefits and service that may be of interest to you as well as communicate with individuals involved in your care or payment for your care. Disclosures to Our Business Associates- There are some services provided by us through contracts with business associates. When these services are contracted for, we may disclose health information about you to our business associates so that they can perform the job we have asked them to do and bill you and your third-party payer for service rendered. To protect your health information, we require the business associates to appropriately safeguard the health information. Victims /Abuse, Neglect, or Domestic Violence- We may disclose your health information to a government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect, or domestic violence. Marketing Communication. We must obtain your written authorization prior to using your health information to send you any marketing materials. We may communicate with you about products or services relating to your treatments, care or alternative treatments, or provides without authorization. When We May Not Use or Disclose Your Health Information Except as described in the Notice of Privacy Practices, we will not use or disclose your health information without your written authorization. If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. You Have the Following Rights With Respect To Your Health Information You have the right to request restrictions on certain uses and disclosures of your health information. To make sure a request, you must complete the Restriction of the Use of Patient Information Form. We are not required to agree to the restriction that you request. You have the right to inspect and copy your health information as long as we maintain your health information. Your health information usually will include prescription and billing records. To inspect or copy your health information, you must complete the Request to Inspect Medical Records Form. We may charge you a fee for the cost of copying, mailing, or other supplies that are necessary to grant your request that the denial be reviewed. You have the right to request that we amend your health information that is incorrect or incomplete. To request an amendment, you must complete the Request to Amend Medical Records Form. We are not required to change your health information and we will provide you with information about procedure for addressing any disagreement with the denial. You have the right to receive an accounting of disclosures of your health information we have made after April 14, 2003, for most purpose other than treatments, payment, health care operation, information provided to you, and certain government functions. To request an accounting, you must complete Request for Accounting of Disclosures Form. You must specify the time period by may not be longer than six years. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time. You may request communication of your health information by alternative means or at alternative location. For example, you may request that health information; you must complete the Request for Alternative Communication Form. Your request must state how or when you would like to be contracted. We will accommodate all reasonable requests. If you wish to exercise one or more of these rights, please contact this office at the above address or phone number. Changes to this Notice of Privacy Practices We reserve the right to amend our practices and this Notice of Privacy Practices at any time in the future and to make the new notice effective for all medical information we maintain. Until such amendment is made, we are required by law to comply with the notice. The revised notice will be posted in this office and a paper copy will be available upon request. For More Information or to Report a Problem If you have any questions or would like additional information about our privacy practices, you may contact us at the above address or phone number. If you believe your privacy rights have been violated, you may file a written complaint, for which there will be no retaliation, with our form or with the Secretary of Health and Human Services.
Please check to agree to the terms described above*
- I acknowledge that I have received the Notice of Privacy Practices
(Type) Signature of Patient, Parent, Guardian or Personal Representative*
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Comments
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PATIENT INFORMATION:

RESPONSIBLE PARTY:

VISION INSURANCE:

MEDICAL INSURANCE:

PATIENT OCULAR HISTORY:

PATIENT MEDICAL HISTORY:

PATIENT MEDICATIONS:

SOCIAL HISTORY:

LIFESTYLE QUESTIONS:

FAMILY OCULAR/MEDICAL HISTORY:

Doctor Recommendations for Your Visit

Certification and Assignment

NOTICE OF PRIVACY PRACTICE