Vision Source - Online Patient Forms

Name

Title:
*First Name:
Middle Initial:
*Last Name:
Suffix:
Nickname:

Address

*Address1:
Address2:
*City:
*State:	*Zipcode:

Contact Information

*Home Phone:
Work Phone:
*Cell Phone:
*Email:
Preferred Contact:

Peronsal Information

Sex	Male Female
*Date of Birth:	(mm/dd/yyyy)
*SSN:	(###-##-####)
Marital Status:
Employment Status:	Employed Full-Time Student Part-Time Student
Employer/School:
Occupation:
Guardian's Name	(if minor)

Doctors' Information

Preferred Eye Doctor:
Primary Care Doctor:

Billing Information

Same as patient data (above)?

Title:
First Name:
Middle Initial:
Last Name:
Suffix:

Address1:
Address2:
City
State	ZipCode:

Home Phone:
Work Phone:

Vision Insurance Plan

Insurance Name:
Insurance Plan:
Insurance ID:
Policy Group:

Vision Insurance - Primary Account Holder

Check here if the patient is not the "primary" on the account:

If the patient is NOT the primary, please complete the information below:

Primary's Name:	(Last, First, MI)
Relationship:	Spouse Child Other
Primary's Sex:	Male Female
Primary's Address:
City:
State:	Zipcode:
Primary's Phone:
Primary's DOB:	(mm/dd/yyyy)
Primary's SSN:	(###-##-####)
Primary's Employer:

Medical Insurance Plan

Insurance Name:
Insurance Plan:
Insurance ID:
Policy Group:

Medical Insurance - Primary Account Holder

Check here if the patient is not the "primary" on the account:

If the patient is NOT the primary, please complete the information below:

Primary's Name:	(Last, First, MI)
Relationship:	Spouse Child Other
Primary's Sex:	Male Female
Primary's Address:
City:
State:	Zipcode:
Primary's Phone:
Primary's DOB:	(mm/dd/yyyy)
Primary's SSN:	(###-##-####)
Primary's Employer:

Consent To Use Or Disclose Health Information
For Treatment, Payment, and Healthcare Operations In the course of providing health care to you, we may need to create, receive, and/or store health information that potentially identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for services, and to conduct healthcare operations involving our office. A comprehensive "Notice of Privacy Practices" is available from our office, that describes in detail the use and disclosure of such health information. You are free to refer to this notice at any time before you sign this consent document. As described in our "Notice of Privacy Practices" the use and disclosure of your health information is necessary for you to receive ongoing care from this office or in conjunction with other health professionals. Our "Notice of Privacy Practices" will be updated when our privacy practices changes. Whenever our practices change you may obtain an updated copy from our offices, or from our webiste at www.visionsource.com. When you sign this consent form, you agree to the use and disclosure of your health information to treat you, to obtain payment for our services, and to perform healthcare operations. You can revoke this consent in writing at any time unless we have already treated you, sought payment for our services, or performed healthcare operations in reliance upon our ability to use or disclose your health information in accordance with this consent. We reserve the right to deny service to you if you elect not to sign this consent form. You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment, or healthcare operations, but as described in our "Notices of Privacy Practices," we are not obligated to agree. If we do agree, however, the restrictions are binding on us. Our "Notices of Privacy Practices" describes how to ask for a restriction.

Insurance Consent I hereby consent to the release of medical information (self, child/dependent, or family member) to the insurance companies responsible for my care. I understand that while my medical records are confidential, information within these records may be required by my insurance company in order facilitate care, and will only be released at their request. I understand that by signing this consent form, I am allowing my medical information to be released upon my insurance company's request, for the purpose of healthcare operations (including but not limited to, provider review function, claims payments, and quality assessment). I also understand that I may revoke this consent by written request at any time with this office. If revoked, it is understood by all parties that all information released prior to being notified of such revocation, was made with my consent.

Financial Policy Thank you for choosing our practices for your eye health needs! Our team of doctors and staff are committed to the highest quality of treatment and care for your medical needs. However, it is very important to understand our financial policies, and that payment for services rendered is integral to this treatment and care.

Contact Lens Policy - (only applicable for patients desiring contact lenses) All contact lenses are "medical devices" according to federal law, and as such, require a proper fitting (in addition to the routine examination) to ensure ocular health. For patients who would like to be fit with contact lenses, the doctor performs a comprehensive eye exam to check the overall health of your eyes, as well as additional testing to assess the fit, prescription, and type of contact lens that best suits your eyes. The contact lens fee also includes a pair of trial contact lenses and follow-up visit(s) when needed, to check or alter the parameters of your contact lens prescription. Fees that are paid for examinations, contact lens evaluation/fitting, and progress checks for contacts lenses are non-refundable. A period of 30 days is allowed for all contact lens follow-up visits. A separate charge for any additional visits past the 30-day time frame may apply. Your prescription will be "finalized" once the doctor has determined an appropriate and healthy lens that you are satisifed with, and you have expressed to us that you would like to proceed with an order. Once an order is placed, contact lens manufacturers will not honor contact lens returns, so we are unable to provide refunds for returned boxes.

No Show/Cancellation Policy - It is important to be present at the date and time of your appointment. Failure to honor your appointment slot, or arriving late for you appointment is unfair to other patients who wanted that appointment time, as well as to our doctors and staff that have been scheduled accordingly. For these reasons, patients who do not respect our appointment policy may be subject to a "no-show" or "cancellation" fee. Please call us at least 24 hours in advance if you need to move your appointment time or date in order to avoid the $25 fee. We understand that emergencies do happen, and as such, we allow patients the following courtesies before the decision is made to decine further service: If a patient does not honor their appointment for 3 consecutive visits or cancel the same day of the appointment up to 3 times.

Insurance Services - Vision Source participates with many health plans. As a courtesy to our patients, we will file claims with these companies. It is ultimately your responsibility for the full and timely payment on your account. Vision Source will attempt to verify coverage and benefits prior to your visit with the physician. If we are unable to verify benefits, we may ask you to pay in full or reschedule your visit until the verification can be obtained. This verification will be used to estimate your financial responsibility; however, this verification is not a guarantee by your health plan of coverage or payment. If your health plan denies any part (or the entirety of your claim), you agree that you are financially responsible for the balance.

Payment - Payment of your estimated patient liability is expected at the time services are rendered. If we participate with your managed care plan or you have a commercial insurance plan under which you are covered, we will bill the carrier for all services rendered. You will be responsible at the time of service for the payment of the annual deductible, co-payments, and charges for non covered services. It is your responsibility to know the benefits and limitations of your vision and health care coverage. Vision Source will provide medically necessary care based on a patient's medical needs, and although we will try to work with your insurance coverage, our main concern is your eye health.

Claim Denials - Please be aware that certain office products, procedures or services may not be covered, or may be considered ânot medically necessaryâ by your health plan. You are responsible for payment of these services. Such procedures and products include but are not limited to: contact lens fittings, specialty contact lenses, specialty eye glass lenses and designer frames, punctual closures, glaucoma scans, visual fields or other medically necessary testing. You will be billed if we obtain a denial from your insurance company and/or we have not received payment from the insurance company within 60 days of our filing your claim.

Past Due Accounts - If your account becomes past due, we will take necessary steps to collect this debt. Referral to a collection agency may adversely impact your credit record. Accounts turned over to collection agencies may also result in you being dismissed for non-payment as a patient from our Vision Source offices.

NSF Checks - There will be a $35 service fee charged to your account if your check is returned by your bank for any reason. Upon notification from our office of your returned check, payment of the entire balance is due immediately. We will accept payment in the form of credit card, cash, or money order. Should you fail to reply within 7 days, our office will forward the balance to Telecheck for collections. There may be additional fees from Telecheck as well.

Private Pay Patients - If you do not have insurance, payment is expected in full at the time of service.

Product Policy - If you purchase glasses, contact lenses, or other supplies from our offices, please understand that the products/supplies are non refundable. All materials are to be paid in full prior to ordering. If there is a balance due for any other service or material purchase from a previous date, it must be paid prior to ordering new product. We will be happy to adjust your glasses, replace nose pads, and screws at no charge. A shipping charge of $15 is required when ordering product including warranty replacements. Some exclusions may apply.

Medicare Notice - We are Medicare participating providers; therefore, we will bill Medicare directly. However, as with any insurance carrier, you will be responsible at the time of services for payment of:
   •  The annual deductibles
   •  Co-payments
   •  Charges for non-covered services
You will also be asked to sign an Advanced Beneficiary Notice (ABN) form in the event a service is provided, which we know is not covered by Medicare.

Payment Methods - For your convenience we accept cash, pre-printed NON temporary checks, Visa, MasterCard, American Express, Care Credit, and Discover. If you have any questions please do not hesitate to ask us. We are here to assist you in any way possible.

Photo & Social Media Policy Vision Source uses a variety of resources to publicize events, products, and services. Should you object to a photograph or other electronic image of you or your child on social media, the company website, marketing brochures, publications, newsletters, or other media coverage prepared for use both inside and/or outside Vision Source, please notify our office in person

*I have read and agree to the policies outlined above

Optomap Information As part of your annual eye examination, our doctors will assess the health of the anatomical structures at the back of the eye including your optic nerve, macula, blood vessels, and other various retinal tissues. This portion of the examination is critical in detecting vision problems, diagnosing ocular diseases such as glaucoma and macular degeneration, as well as screening for systemic health conditions such as diabetes and high blood pressure. There are two primary methods we utilize to evaluate your retinal health, as outlined below.

• Standard Dilation - Drops are instilled into your eyes that (over a period of 20-30 minutes) will dilate the pupils and allow the doctor to view your retina with a series of lenses. Although the doctor can only see a small portion of the retina at any given moment, an evaluation of the entire retina is possible utilizing various lenses and eye positions. Side effects of the dilation drops typically include light sensitivity, and blurred vision for 4-6 hours following the dilation.

• Optomap Imaging - The "optomap" is a widefield retinal imaging system designed to provide you and your doctor with archivable images of your retinal structures. The optomap requires no dilation drops to obtain the images, takes only seconds to perform, and the results are instantaneous. When you choose optomap as a part of your eye examination, your doctor will review your retinal health with you in the exam room, and we will maintain your widefield retinal photos in our database to serve as a basis of comparison for years to come: this means earlier detection of ocular health complications than would otherwise be possible without this technology. For these reasons, Optomap is the preferred option for all of our patients. However, please be aware that Optomap imaging may not be a covered service under some vision insurance plans.

Submit Form

Please be sure that you have completed all required fields
("Demographics" Tab and "Policies and Consent" Tab)
and then click "Submit Data"

Year/Date of last health exam?:

Chronic Conditions or Illnesses (ie: Diabetes, Hypertension, etc...):
1)	4)
2)	5)
3)	6) Are there more?

Medications/Vitamins/Supplements (and dosage if known):
1)	4)
2)	5)
3)	6) Are there more?

Any known drug allergies?:	YesNo
If yes, what medications?:
Symptoms of Drug Allergies:

Are you currently pregnant or nursing?

Last Blood Sugar reading?:	or Unknown
When was this reading taken?:

Last HbA1c value?:	% or Unknown

Is your diabetes currently:	Controlled or Not Controlled
How often do you see your diabetes doctor?:

Ocular Medications (and dosage if known):
1)	4)
2)	5)
3)	Are there more?

Have you ever been diagnosed with any of the following eye conditions?
Eye Condition:	Additional Information:
Glaucoma: Yes or No
Cataract: Yes or No
Macular Degeneration: Yes or No
Corneal Disease: Yes or No
Retinal Problems: Yes or No
Amblyopia/Lazy Eye: Yes or No
Crossed Eyes: Yes or No
Eye or Lid Infection: Yes or No
Other: Yes or No

Do your family members have a history of any the following:
Eye Conditions :	Relationship to Patient (if "yes"):
Lazy Eye: Yes or No
Blindness: Yes or No
Cataract(s): Yes or No
Color Blindness: Yes or No
Glaucoma: Yes or No
Macular Degeneration: Yes or No
Retinal Detachment: Yes or No
Eye Turn: Yes or No

Systemic Diseases:	Relationship to Patient (if "yes"):
Arthritis: Yes or No
Cancer: Yes or No
Diabetes: Yes or No
Heart Diease: Yes or No
High Blood Pressure: Yes or No
Kidney Disease: Yes or No
Lupus: Yes or No
Stroke: Yes or No
Thyroid Disease: Yes or No
Other: Yes or No

If so, what type(s)?:
	Single Vision	Progressives
	Bifocals	Trifocals
	Backup Glasses	Safety Glasses
	Sports Glasses	Other

Have you ever tried contact lenses?	Yes or No
Do you currently wear contacts?	Yes or No
If yes, hours worn per day:

Occupation:
Do you use the computer at work?	Yes or No
If yes, how many hours per day?

Do you Drive?	Yes or No

Do you exercise regularly?	Yes or No

Do you drink alcohol?

Smoking/Tobacco Use?
If yes, type of use:

Main reason for visit:
Secondary Reasons:
Additional Info:

Welcome to our online patient forms!