Provision Eyecare Center Patient Forms

Your Demographic Information

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Miss Dr. Rev.

Address

City	State	ZipCode
	NJ NY AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NM NV OH OK OR PA RI SC SD TN TX UT VA VI VT WA WI WV WY

Home Phone:
Other Phone:
Cell Phone:		Preferred Contact:	Home Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female
Marital Status	Annulled Divorced Domestic partner Legally Separated Married Never Married Polygamous Widowed
Misc/Guardian

Payment Information

Type:	DEBIT CARD CREDIT CARD - DISCOVER CREDIT CARD - MASTERCARD CREDIT CARD - VISA
Card Number:
Security Code:		Expiration (xx/xxxx):
Name of Cardholder:
Billing Zip:

Vision Insurance

Vision Insurance Information

Vision Insurance Name:	None AARP ACI Advantica Aetna Agentra AMERIGROUP AMERIHEALTH Avesis BCBS Chesterfield Resources Cigna CLOVER CPS Optical Davis Vision Delta Emblem Health / GHI EYEMED GHI GPA Guardian Heritage HIP HORIZON Humana Independence Magnacare MARCH MEDICAID MEDICARE Meritain MES vision NVA Oscar QUALCARE QVN Spectera SUPERIOR VISION Tricare UMR UNITED HEALTHCARE VBA Vision Care Direct Vision Screening VSP Wellcare
Insurance Plan:
Insurance ID:
Insurance Policy Group:

I am not the Primary policyholder on the Account:

Primary Policyholder Information

Name:	Last, First, MI
Patient's Relationship to Primary:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical Insurance

Medical Insurance Information

Medical Insurance Name:	None AARP ACI Advantica Aetna Agentra AMERIGROUP AMERIHEALTH Avesis BCBS Chesterfield Resources Cigna CLOVER CPS Optical Davis Vision Delta Emblem Health / GHI EYEMED GHI GPA Guardian Heritage HIP HORIZON Humana Independence Magnacare MARCH MEDICAID MEDICARE Meritain MES vision NVA Oscar QUALCARE QVN Spectera SUPERIOR VISION Tricare UMR UNITED HEALTHCARE VBA Vision Care Direct Vision Screening VSP Wellcare
Insurance Plan:
Insurance ID:
Insurance Policy Group:

I am not the Primary policyholder on the Account:

Primary Policyholder Information

Name:	Last, First, MI
Patient's Relationship to Primary:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Reason for Visit:

Routine - need new glasses Routine - need more contact lenses Diabetic eye exam Failed screening at school or pediatrician's office I want to wear contacts for the first time Eye infection Other

Medications: No Meds Used	Over The Counter Medications:

Vitamins:	Drug Allergies: No Known Drug Allergies

Please describe any injuries, surgeries, or hospitalizations (we'll ask for eye-related incidents later):

Your Primary Care Doctor:

Last Visit:

1 week 1 month 3 months 6 months 1 year 2 years greater than 3 years Other

Reason:

Check up Annual Specific Other

Pregnant Or Nursing:

No Yes Unsure Other

Recent Tetanus Shot:

Yes No Other

Recent Flu Immunization:

Yes No Other

Do you have any of these medical conditions? Please describe:

Diabetes:		Year Diagnosed:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Family Medical History

Unknown family history

Does anyone in your family have these medical conditions? Please describe:

Diabetes:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Your Eye History

Do you currently have any of these symptoms?:	None Itching Burning, Stinging Red Floaters Flashes Of Light Eye Injuries Eye Surgery Amblyopia Strabismus Cataracts Glaucoma Retinal Disorders Other
Do you take any eye drops or eye medications?:	None Cromolyn NA 4% Visine Patanol Xalatan Travatan rewetting drops Elestat Vigamox Alphagan Refresh Theratears Genteal Pred Forte Lotemax Alrex Systane Blink Other

Have you had any eye injuries or surgeries? Please describe:

Last Eye Exam:	1 year 2 years 3 years Other	By Doctor:

Primary Vision Correction:

None Prescription Glasses Prescription Reading Glasses Soft Contacts Non-Prescription Reading Glasses Other

Do you:    Have back up glasses?

No Yes Other

Want new glasses?

Yes No Other

Want backup sunglasses?:

Contact Lens Wearers only

Name or type of contacts worn in the past:

Name of Cleaning Solution:

Disposal interval:

Daily Weekly Biweekly Monthly Other

Wear Time:

Your Family Eye History

Macular Degen:	No Parents Siblings Grandparent Other	Glaucoma:	No Parents Sibling Grandparent Other
Retinal Detach:	No Parents Siblings Grandparent Other	Cataracts:	No Parents Siblings Grandparent Other
Lazy/Crossed Eye:	No Parents Siblings Grandparent Other	Blindness:	No Parents Siblings Grandparent Other

Review of Systems

General:	None Fatigue Fever Loss of Appetite Weight Gain Weight Loss Developmental Disorders Other	Ear/Nose/Throat:	None Neck Problems Sinus Problems Sore Throat (Recent) Headache Morning Headaches Migraine Headache Cluster Headache Hearing Loss Tinnitus Congestion Dry throat / mouth Sleep Apnea Other
Skin:	None Acne Lupus Dermatitis Eczema Psoriasis Rosacea Skin Cancer Itching Other	Cardiovascular:	None Congestive Heart Disease Cardivascular Disease High Cholesterol Hypertension Arrhythmia Heart Murmur Heart Palpitation Chest Pain Arteriosclerosis Coagulation Disorder Mitral Valve Prolapse Low Blood Pressure Other
Respiratory:	None Asthma Cancer: lung Sleep Apnea Sarcoidosis COPD Emphysema Pneumonia Bronchitis Shortness of breath Wheezing Other	Musculoskeletal:	None Arthritis Osteoporosis Fibromyalgia Osteoarthritis Muscular Dystrophy Lupus Decreased range of motion Muscle cramps Pain/tenderness Stiffness Swelling Weakness Other
Psychiatric:	None Attention Deficit Disorder Anxiety Brain Damage (trauma) Panic Attacks Alzheimers Disease Bi-polar Depression Insomnia Obsessive/Compulsive Paranoia Suicidal Violence Other	Gastrointestinal:	None Acid Reflux Crohn's disease Gastric reflux (GERD) IBS Ulcer Gall bladder problems Jaundice Hepatitis Sarcoidosis Cancer: colon Cancer: Liver Other
Endocrine:	None Crohn's disease Diabetes Type 1 Diabetes Type 2 Diabetes Suspect Hypothyroid Hyperthoyroid Gout Hormone Replacement Therapy Other	Blood/Lymph:	None Anemia Hx of Significant Blood Loss Hematologic Disorder Sickle Cell Disorder Breast Carcinoma Lymph Node Disease Temporal Arthritis Cuts slow to clot Easy bruising Other
Neurological:	None Multiple Sclerosis Seizure Disorder Parkinsons Disease Brian Tumor Bells Palsy Dyslexia Headache Balance problems Vertigo Tremors Changes in senses Dementia Memory problems Muscle weakness Numbness, paralysis Personality changes Speech problems Other	Genitourinary:	None Amenorrhea Menopause Impotence Jaundice Uterine Cancer Prostate Cancer Kidney Stones Pregnant Nursing Syphilis Prostate Problems Bladder Infections STD- herpetic STD- chlamydia Other
Immune:	None Seasonal allergies Environmental allergies Food allergies Drug allergies (please specify) Sjogrens syndrome AIDS Herpes Simplex HIV Simplex Mononucleosis Tuberculosis Cytomegalovirus Infection Herpes Zoster Lyme Disease Sarcoidosis Syphilis Hives Itching Mild allergy symptoms Severe allergy symptoms Swelling Other

Social History

Hobbies:

None Art Baseball Astronomy Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking Other

Smoking Status:	Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other	Type:	None Cigarettes Chewing Tobacco Other	How Long:
Alcohol Use:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Illegal Drug Use:	No Yes Other	Type:		How Long

STD's:

None Gonorrhea Syphilis Hepatitis HIV TB Other

Race:

White Black or African American Asian Patient Declined to Specify American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Other Race Other

Ethnicity:

Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other

Preferred Language:

English French German Spanish Other

Top

Office Policies

NOTICE OF PRIVACY PRACTICES

This Notice applies to individuals receiving services from Provision Eyecare Center and does not require your response. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

YOUR RIGHTS

• Right to see and copy your records. In most cases, you have a right to view or get copies of your records. You must make your request in writing. We will provide a response to your request within thirty (30) days. You will be charged a fee for the cost of copying your records.
• Right to an electronic copy of your medical records. If your information is maintained in an electronic format, you may request that your electronic records be transmitted to you or another individual or entity. We will respond to your request within thirty (30) days.
• Right to correct or update your records. You may ask us to correct your health information if you think there is a mistake. You must make your request in writing and provide a reason for your need to correct the information.
• Right to choose how we communicate with you. You may ask us to share information with you in a certain way. For example, you can ask us to send information to your work address instead of your home address. You must make this request in writing. You don’t have to explain a reason for the request. We may deny unreasonable requests.
• Right to get a list of disclosures. You have a right to ask us for a list of disclosures made after April 14, 2003. You must make a request in writing. This will not include information shared for treatment, payment or health operation purposes. We will provide one accounting a year free of charge, but may charge a cost for additional lists provided within the 12 month period.
• Right to get notice of a breach. You have a right to be notified upon a breach of any of your protected health information.
• Right to request restrictions on uses or disclosures. You have a right to ask us to limit how your information is used or shared with others. You must make the request in writing and indicate what information should be limited. We are not required to agree to a requested restriction. If you paid out-of-pocket expenses in full for a specific item or service, you have a right to ask that your information with respect to that item or service not be disclosed. We will always honor that request.
• Right to revoke authorization. If we ask you to sign an authorization to use or disclose your information, you can cancel that authorization at any time. You must make that request in writing. Your request will not affect information that has already been shared.
• Right to get a copy of this notice. You have a right to ask for an electronic or paper copy of this notice at any time.
• Right to file a complaint. You have a right to file a complaint if you don’t agree with how we have used or disclosed your information.
• Right to choose someone to act for you. If someone has been legally designated as your personal representative, that person can exercise your rights and make choices about your health.

OUR DUTIES
Provision Eyecare Center must collect information about you to provide healthcare and related services. We are required to protect your information according to federal and state law and will abide by the terms of this notice. We may use and disclose information without your authorization for the following purposes:

• Treatment Purposes. We may use or disclose your information to health care providers who are involved in your health care.
• Payment. We may use or disclose your information to get payment or pay for health care services you received or will receive.
• Health Care Operations. We may use or disclose your information in order to manage our business, improve your care and contact you when necessary.
• As Required by Law. We will disclose information to a public health agency that maintains vital records, such as births, deaths and some diseases.
• Abuse and Neglect Investigations. We may disclose your information to report all potential cases of abuse and/or neglect.
• Health Oversight Activities. We may use or disclose your information to respond to an inspection or investigation by state officials.
• Government Programs. We may use and disclose your information for the management and coordination of public benefits under government programs.
• To Avoid Harm. We may use and disclose information to law enforcement in order to avoid a serious threat to the health and safety of a person or the public.
• For Research. We may use and disclose your information for studies and to develop reports. These reports will not specifically identify you or another person.
• Business Associates. We may use and disclose your information to our business associates that perform functions on our behalf, if necessary to complete those functions.
• Organ and Tissue Donation. If you are an organ donor, we may use and disclose your information to organizations engaged in procuring, banking or the transportation of organs, eyes, or other tissues to facilitate organ transplantation.
• Military and Veterans. If you are a member of the armed forces, we may disclose your information to the appropriate military authority.
• Workers Compensation. We may use or disclose your information for workers compensation or similar programs providing benefits for work-related injuries or illnesses.
• Data Breach Notification Purposes. We may use or disclose your information to provide legally required notices of unauthorized access or disclosure of your health information.
• Lawsuits and Disputes. We may use or disclose your information in response to a Court or Administrative Order, subpoena, discovery request or other lawful process.
• Law Enforcement. We may disclose your information to law enforcement if the information: 1) is in response to a court order, subpoena, warrant or similar process; 2) limited to identify or locate a suspect, fugitive, material witness or missing person; 3) about a victim of a crime under very limited circumstances; 4) about a death potentially resulting from a crime; 5) about criminal conduct on any DHS property and; 6) is needed in an emergency to report a crime or facts surrounding a crime. Coroner, Medical Examiners and Funeral Directors. We may disclose your information to a Coroner or Medical Examiner to identify a deceased person or determine the cause of death. We may release your information to a Funeral Director as necessary for their duties.
• National Security and Intelligence. We may disclose your information to authorized federal officials for intelligence, counter-intelligence and other national security activities authorized by law.
• Protective Services for the President and Others. We may disclose your information to authorized federal officials so that they can provide protection to the U.S. President; other authorized persons or foreign heads of state, or to conduct special investigations.
• Inmates or Individuals in Custody. If you are an inmate, we may release your information to a correctional institution if that information would be necessary for the institution to: 1) provide you with health care; 2) protect your health and safety or the health and safety of others or: 3) for the safety and security of the correctional institutions.
• Disclosure to Family, Friends and Others. We may disclose your information to your family members, friends or other persons who are involved in your medical care. You may object to the sharing of this information. We may also share your information with someone legally designated as your personal representative. Hospital Directory. Unless you notify us that you object, we may include certain information about you in the hospital directory in order to respond to inquiries from friends, family, clergy and others who inquire about you when you are a patient in the hospital.

Other Uses and Disclosures that Require Your Written Authorization

• For All Other Situations. We will ask for your written authorization before using or disclosing information for any other purpose than what is mentioned above. Special circumstances that require an authorization include most uses and disclosures of your psychotherapy notes, certain disclosures of your test results for the human immunodeficiency virus or HIV, uses and disclosures of your health information for marketing purposes and for the sale of your health information with some exceptions. If you give us authorization, you can withdraw this written authorization at any time. To withdraw your authorization, please contact us at the number on our website. If you revoke your authorization, we will no longer use or disclose your health information as allowed by your written authorization, except to the extent that we have already relied on your authorization.
• As Required by Other Laws. We will ask for your written authorization to comply with other laws protecting the use and disclosure of your information.

CHANGES TO THIS NOTICE
In the future, Provision Eyecare Center may change its Notice of Privacy Practices. Any change could apply to medical information we already have about you, as well as information we receive in the future.
A copy of a new notice will be posted in our facilities/offices and provided to you as required by law. You may ask for a copy of our current notice or get it online on our website.

By e-signing below, I acknowledge that I have reviewed and agree to this notice.

POLICIES

At Provision, our goal is to help you get top quality care for your condition. We are committed to building a successful physician-patient relationship with you and your family. It is your responsibility to notify our office of any patient information changes (i.e. address, name, insurance information, etc). Provision recommends that you know the details of your plan before your health care visits.

If your insurance company requires a referral and/or preauthorization for your visit, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower or no payment from the insurance company, and the balance will be your responsibility.

Co-pays, co-insurances, and past due balances are due at the time of scheduling, prior to the service, unless arrangements have been made with a billing coordinator. You are obligated to pay your portion prior to insurance paying the rest of the claim. Our financial contract is with you, not with your insurance. If there are any unpaid amounts you will be sent a statement to inform you of your account status. There are several reasons why you may be receiving a statement, even with insurance. Some of the most common are: Insurance has denied the claim. Insurance has applied the claim to a deductible. Insurance has not received a copy of your claim, usually due to incomplete/invalid information. Accurate insurance information has not been provided; an old insurance is being billed. We have received a response from your primary insurance and are in the process of billing your secondary insurance. Insurance has processed the claim and left a higher co-pay amount than what was paid at the time of service. If we don't receive a copy of your current insurance card at the time of service, your account is considered to be self-pay until we receive a copy. Although we have specific prices assigned to each service we provide, we can't determine what the cost for your visit is until your needs have been determined from your evaluation. You may request for an estimate of charges, but a final determination cannot be made until the physician has determined your needs. If you find your insurance carrier has denied payment, please first review your plan details with your insurance company. While our staff is sympathetic and wants to assist you, the most they can do is to double-check to see if there were any errors in submitting your claim. However, we have to repeatedly stress, the signed billing agreement we have with all of our patients places the ultimate responsibility for covering any charge an insurance carrier doesn't cover (pays at zero) on the patient/family.

Late Cancellations: A late cancellation is considered when a patient fails to cancel their scheduled appointment with a 24 hour advance notice.
No-shows: A no-show is when a patient misses an appointment with no notice or shows up too late to the appointment to be seen.
A fifty dollar fee will be billed to your account for late cancellations and for no-shows. Repeatedly missing visits jeopardizes your care. For this reason after an Established patient has two (2) late cancellations and/or no-shows or a NEW PATIENT has one (1) cancellation or no-show, they will be discharged from the practice.

We will make attempts to collect past dues. If no resolution can be made, the account will be sent to the collection agency, or attorney, and possible discharge from the practice. In the event an account is turned over for collections, the person financially responsible for the account will be responsible for all collections costs including attorney fees and court costs. Regardless of any personal arrangements that a patient might have outside of our office, if you are over 18 years of age and receiving treatment, you are ultimately responsible for payment of the service. Our office will not bill any other personal party. This financial policy helps the office provide quality care to our valued patients. If you have any questions or need clarification of any of the above policies, please feel free to contact us.

By e-signing below, I authorize Provision to charge my credit card for agreed upon professional fees, services, and purchases. Services rendered are non-refundable. I understand that my information will be saved to file for future transactions on my account. This authorization will remain in effect until cancelled.

By e-signing below, I hereby authorize Provision to apply for benefits on my behalf and for payment of medical benefits directly to Provision for services rendered. I request payments of any insurance company to be made directly to Provision. Authorization is hereby granted to release information contained in the patients’ medical record or the patient’s medical insurance company (or its employees or agents) as may be necessary to process and complete the patient’s medical claim. I understand that I am financially responsible for all charges for services rendered which may include services not covered by the patient’s insurance companies. I agree that all amounts are due upon request and are payable to Provision. I further understand that should my account balance become delinquent and sent to a third-party collector, I agree to pay an additional thirty perecent of the balance or fifty dollars, whichever is greater.
The duration of this authorization is indefinite and continues until revoked in writing. I understand that by not signing this release of information, I am responsible for payment of services in full before services are rendered.

CONSENT TO TREAT

I (patient or legal guardian) hereby authorize employees and agents of Provision including physicians, physician assistants and other employees and staff members to render medical evaluations and care to the patient indicated below. The duration of this consent is indefinite and continues until revoked in writing. I understand that by not signing this consent, the patient will not be provided medical care except in the case of an emergency.


By e-signing below, I agree to the above statement.

 

OPTOMAP POLICY

Provision and our doctors are committed to delivering the highest quality and highest standard of care to you. We use Optomap technology to make sure every part of your retina (inside your eye) appears healthy at each visit. Your insurance may cover this procedure. It is a safe, non-invasive procedure to take accurate, high definition images. It typically captures up to 5x more information inside your eyes than other techniques and technologies to ensure you are receiving the most thorough and comprehensive eye care at Provision. It is suitable for all ages, even newborns. No eye drops are used to obtain the images, which means no dilation, and no side effects. Your Optomap results will be reviewed with you during your consultation. The images captured during your visit are part of your permanent record and enables our doctors to make important comparisons at each eye exam.

For more information, you can watch this video

You can also visit their website https://www.optomap.com/optomap-screening/

By e-signing below, I agree that I consent to and am responsible for the Optomap procedure.

 

CDC GUIDELINES AND COVID-19 PATIENT DISCLOSURES

Provision is committed to reducing risk and exposure to COVID-19 and infectious diseases according to CDC guidelines to protect you, our patients, and staff. If you have any of these symptoms on the day of your appointment, or if you may have had exposure, we ask that you contact our office immediately and/or reschedule.

• Fever in the past three days
• Cough
• Congestion or runny nose
• New loss of taste or smell
• Sore throat
• Vomiting
• Diarrhea
• Shortness of breath or trouble breathing
• Recently tested positive for COVID-19
• Recently been in contact with someone who has COVID-19 (exposure longer than 15 minutes)

By e-signing below, I agree that I do not have COVID-19, I do not exhibit any symptoms suggestive of COVID-19 or been in contact with someone who has COVID-19 on the day of my appointment. I understand and agree that if this is no longer true, I am responsible for informing the staff at Provision and would possibly need to reschedule.

PROVISION EYECARE CENTER RESERVES THE RIGHT TO CHANGE AND/OR MODIFY THE INFORMATION ON THIS SITE AT ANY TIME.

Submit

E-signature (type your name): Date: