New Patient Form

Demographics

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

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

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Annulled Divorced Domestic Partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Whipple, Deon Dr. Reed, John W. Dr. Whipple, Destin D.	Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

Address

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

Home Phone:
Work Phone:

Primary

Insurance Information (Please fill in vision benefits information on primary insurance page.)

Insurance Name:	None - Cash Pay AARP Medicare Complete/UHC Aetna/Eyemed Aetna/Medical Claims Always Care/First Look Vision Network AmeriBen AVESIS AZ Pipe Trades BCBS BCBS/MERITAIN/ASBAIT CIGNA/medical claims Davis Vision EYE MED GILSBAR HealthNet of AZ/MEDICARE/Eyemed Humana Vision Care Plan MEDICARE Medicare Solutions MMSI /TOWN OF GILBERT OptiCare of Utah/First Look Other Palmetto GBA-RR MEDICARE Sight Care Southwestern Eye Center Spectera Eye Care Networks Superior Ins. UHC MEDICARE ADVANTAGE V B A VISION CARE DIRECT VSP VSP-Choice Reed VSP-Choice Whipple VSP-Signature Reed VSP-Signature Whipple
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

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

Secondary

Insurance Information

Insurance Name:	None AARP Medicare Complete/UHC Aetna/Eyemed Aetna/Medical Claims Always Care/First Look Vision Network AmeriBen AVESIS AZ Pipe Trades BCBS BCBS/MERITAIN/ASBAIT CIGNA/medical claims Davis Vision EYE MED GILSBAR HealthNet of AZ/MEDICARE/Eyemed Humana Vision Care Plan MEDICARE Medicare Solutions MMSI /TOWN OF GILBERT OptiCare of Utah/First Look Other Palmetto GBA-RR MEDICARE Sight Care Southwestern Eye Center Spectera Eye Care Networks Superior Ins. UHC MEDICARE ADVANTAGE V B A VISION CARE DIRECT VSP VSP-Choice Reed VSP-Choice Whipple VSP-Signature Reed VSP-Signature Whipple
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

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

Tertiary

Insurance Information

Insurance Name:	None AARP Medicare Complete/UHC Aetna/Eyemed Aetna/Medical Claims Always Care/First Look Vision Network AmeriBen AVESIS AZ Pipe Trades BCBS BCBS/MERITAIN/ASBAIT CIGNA/medical claims Davis Vision EYE MED GILSBAR HealthNet of AZ/MEDICARE/Eyemed Humana Vision Care Plan MEDICARE Medicare Solutions MMSI /TOWN OF GILBERT OptiCare of Utah/First Look Other Palmetto GBA-RR MEDICARE Sight Care Southwestern Eye Center Spectera Eye Care Networks Superior Ins. UHC MEDICARE ADVANTAGE V B A VISION CARE DIRECT VSP VSP-Choice Reed VSP-Choice Whipple VSP-Signature Reed VSP-Signature Whipple
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

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

Reason for Visit

Nothing changed since previous exam

How did you find us?

Doctor referral Friend/family Returning patient Sign Phone book Internet/website Postcard/mailer Newspaper/radio/TV Other

Reason for Visit:

Vision blurry vision blurry @ distance vision blurry @ near vision blurry @ distance and near Vision blurry without glasses Vision blurry without contact lenses Family history of vision correction Comprehensive eye examination for diabetes Comprehensive eye examination for high blood pressure Comprehensive eye exam for hight cholesterol Comprehensive eye examination for family history of diabetes Comprehensive eye examination for family history of high blood pressure Eye pain Dry eyes Burning Stinging Itching Watering Lost/Broken glasses Floaters & Flashing lights Red eye, pain even with glasses on injury to eye bump on eyelid sudden loss of vision sudden change in vision eyes turn DMV referral School referral Physician referral Glaucome history Diabetes history Comprehensive eye examination for family history of high cholesterol Other

Last Eye Exam:

1 year 2 years 3 years never years ago cannot remember Other

Doctor:

Are you planning to be dilated?

Yes No Discuss with doctor Other

Would you like retina photos today?

Yes No Speak with doctor Other

Eye medications/drops:

None Visine rewetting drops Patanol Xalatan Travatan Refresh Ciloxan Vigamox Elestat Alphagan Theratears Genteal Pred Forte Lotemax Alrex Systane Blink Cromolyn NA 4% Artificial Tears Other Visual Symptoms Other

Glasses use:

None All day wear Reading/near only Distance only Computer UV Protection Glare reduction yes Other

Interested in trying contact lenses?

Yes No Maybe Other

Contact lens use:

None All day wear Distance + readers over Multifocal Monovision Other

Current brand:

Acuvue Oasys Acuvue 2 Air optix aqua Air optix night/day Biofinity Biomedics Purevision Soflens Trueye Dailies Other

Are you happy with your contact lenses?

Yes No Other

Contact lens solution:

Optifree Pure Moist Bio True Renu Revitalens Clear Care Sauflon One Step Sauflon Lite Other Other

Contact lens replacement:

Daily Every 2 weeks Every Month Every 2 months Other Other

Sleep in CLs?

Never Occasionally Nightly Naps only 1-2x/week Other

OCCUPATION:

HOBBIES/OTHER VISUAL DEMANDS:

Lens Replacement/Cataract Removal:

None Right Left Both Other

When:

Refractive Surgery/LASIK:

None Right Left Both Other

When:

Laser Eye Procedure:

None Right Left Both Other

When:

Other Visual Symptoms(choose as many as apply):

Flashes FloatersHeadache Itching BurningDouble Vision Strain Discharge Haloes Sandy

Other Notes:

Medical History

If you have a symptom different from the ones listed, please select 'Other' in the dropdown list and submit it in the box provided. Do you currently have any of these problems? GENERAL: Fever, weight loss, weight gain, fatigue?

None Fever Cold Flu Other

EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat

None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Other

CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease,

None High BP Surgery Vascular Disease High Cholestrol Other

RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD

None Asthma Bronchitis Emphysema COPD Other

GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination

None painful urination frequent urination impotence jaundice kidney stones incontinence bladder infection Other

MUSCLES, BONES, JOINTS: Arthritis, Head or Neck Injury

None arthritis joint pain stiffness swelling cramps Other

SKIN: growths, rashes, acne

None pimples, warts growths rash roscea acne melanoma Other

NEUROLOGICAL: Headaches, migraines, seizures

None numbness, paralysis headache seizures migraines head trauma Other

PSYCHIATRIC: Depression, Anxiety, Insomnia

None anxiety depression insomnia schizophrenia Bipolar Alzheimer's dementia Other

ENDOCRINE: Diabetes ,Thyroid

None diabetes hypothyroid hyperthoyroid Diabetes Type I Diabetes Type II Other

BLOOD/LYMPH: CHOLESTEROL, Anemia, bleeding problems

None bleeding cholestrolemia anemia Other

ALLERGIC / IMMUNOLOGIC: Seasonal, Rheumatoid, AIDS, Lupus

None Seasonal allergies sneezing swelling redness itching hives lupus Other

GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

None not specified Diarrhea Constipation Ulcer Acid Reflux Other

PRIMARY CARE PHYSCIAN: None Doesn't Have One Doesn't Remember Other   PCP Telephone: 

         PCP Address:   PCP Fax: 

When was Your Last Visit?  1 week 1 month 3 months 6 months 1 year 2 years never Other

Have you or any immediate family member ever had any of the following conditions?

Diabetes:

None Self Father Mother Brother Sister Paternal Grandparent Maternal Grandparent Son Daughter Other

Diabetes Type:

2 1 Gestational Insulin dependent Other

Last HbA1c:

Last Blood Glucose:

High blood pressure:

None Self Father Mother Brother Sister Paternal Grandparent Maternal Grandparent Son Daughter Other

Last BP:

Cancer or tumor:

None Self Father Mother Brother Sister Paternal Grandparent Maternal Grandparent Son Daughter Other

Blindness:

None Self Father Mother Brother Sister Paternal Grandparent Maternal Grandparent Son Daughter Other

Glaucoma:

None Self Father Mother Brother Sister Paternal Grandparent Maternal Grandparent Son Daughter Other

Macular degeneration:

None Self Father Mother Brother Sister Paternal Grandparent Maternal Grandparent Son Daughter Other

Retinal detachment/tear:

None Self Father Mother Brother Sister Paternal Grandparent Maternal Grandparent Son Daughter Other

Crossed eye or lazy eye:

None Self Father Mother Brother Sister Paternal Grandparent Maternal Grandparent Son Daughter Other

Cataract:

None Self Father Mother Brother Sister Paternal Grandparent Maternal Grandparent Son Daughter Other

Heart disease: None Self Father Mother Brother Sister Paternal Grandparent Maternal Grandparent Son Daughter Other Heart Disease Type: High cholesterol Coronary artery disease Peripheral artery disease Valve replacement Other Other Blood disorder: None Self Father Mother Brother Sister Paternal Grandparent Maternal Grandparent Son Daughter Other Blood Disorder Type: High cholesterol Anemia Hemophelia Lymphoma Other Other

Autoimmune disease:

None Self Father Mother Brother Sister Paternal Grandparent Maternal Grandparent Son Daughter Other

Autoimmune Disease Type:

Lupus Rheumatic Sjogren syndrome Multiple sclerosis Other Other

Other/surgery/problem:

None Self Father Mother Brother Sister Paternal Grandparent Maternal Grandparent Son Daughter Other

Other/surgery/problem type:

Affordable Healthcare Act Requirements:

Tobacco use?  Never smoker (<100 lifetime cigarettes or equivalent quantity of cigar or pipe smoke) Former smoker (no longer smokes)">Former smoker (no longer smokes)">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) Smoker (current status unknown) Unknown if ever smoked Other

Alcohol use?  No Yes Occasionally Socially Other   X a week: 

Race:  American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify Other   Preferred Language:  English Spanish Other

Weight (LBS):    Height (Feet/Inches): 

Pregnant Or Nursing  Pregnant Nursing Unsure N/A Other    Due Date: 

    Medications: 

Allergies/Alerts: 

Notes:

Privacy Policy

Notice of Privacy Practices

Dr. Destin D. Whipple                     Optometry                     Dr. John W. Reed
    (480) 545-8985                   1356 S. Gilbert Road #3           (480) 545-9120

This notice describes how medical information about you may be used and disclosed,
and how you can obtain access to this information. Please review it carefully.
_______________________________________________________________________________________________

We respect our legal obligation to keep health information, which identifies you, private.
The law obligates us to give you notice of our privacy practices. Generally, we can only use
your health information in our office or disclose it outside of our office, without your written
permission, for purposes of treatment, payment or healthcare operations. In most other situations,
we will not use or disclose your health information unless you sign a written authorization form.
In some limited situations, the law allows or requires us to disclose your health information
without written authorization.

Examples of how we use information for treatment purposes:

• When we set up an appointment for you.
• When our technician or doctor tests your eyes.
• When the doctor prescribes glasses or contact lenses.
• When the doctor prescribes medication.
• When our staff helps you select and order glasses or contact lenses.
• When we show you low vision aids.
• We may disclose your health information outside of our office for treatment purposes, for example: If we refer you to another doctor or clinic for eye care or low vision aids or services. If we send a prescription for glasses or contacts to another professional to be filled.
• When we provide a prescription for medication to a pharmacist.
• When we phone to let you know that your glasses or contact lenses are ready to be picked up. Sometimes we may ask for copies of your health information from another professional that you may have seen before. We may use your health information within our office or disclose your health information outside of our office for payment purposes. Some examples are: When our staff asks you about health or vision care plans that you may belong to, or about other sources of payment for our services.
• When we prepare bills to send to you or your health or vision care plan.
• When we process payment by credit card and when we try to collect unpaid amounts due.
• When bills or claims for payment are mailed, faxed, or sent by computer to you or your health or vision plan.
• When we occasionally have to ask a collection agency or attorney to help us with unpaid amounts due. We use and disclose your health information for healthcare operations in a number of ways. Health care operations means those administrative and managerial functions that we have to do in order to run our office. We may use or disclose your health information, for example, for financial or billing audits, for internal quality assurance, for personnel decisions, to enable our doctors to participate in managed care plans, for the defense of legal matters, to develop business plans, and for outside storage of our records.

APPOINTMENT REMINDERS

We may call, text or email you to remind you of scheduled appointments. We may also call, text, or email you to notify you of other treatments or services that might help you. Uses & Disclosures without an Authorization In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never happen at our office at all. Such uses or disclosures are: A state or federal law that mandates certain health information be reported for a specific purpose. Public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the Food and Drug Administration regarding drugs or medical devices. Disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence. Uses and disclosures for health oversight activities, such as for the licensing of doctors, audits by Medicare or Medicaid, or investigation of possible violations of healthcare laws. Disclosures of judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies. Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office or to report a crime that happened somewhere else. Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations. Uses or disclosures for health related research. Uses and disclosures to prevent a serious threat to health or safety. Uses or disclosures for specialized government functions, such as for the protection of the president or high-ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the Foreign Service. Disclosures relating to workers' compensation programs. Disclosures to business associates who perform healthcare operations for us and who agree to keep your health information private. Other Disclosures We will not make any other uses or disclosures of your health information unless you sign a written authorization form. You do not have to sign such a form. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it.

Your Rights Regarding Your Health Information

The Law gives you many rights regarding your health information.

• 1. You can ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or healthcare operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to us using the address at the beginning of this notice.
• 2. You can ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home or by mailing health information to a different address. We will accommodate these requests if they are reasonable and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to your optometrist at the address shown at the beginning of this notice.
• 3. You can ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. Primarily, however, you will be able to review or have a copy of your health information within 30 days of asking us. You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation and instructions about how to get an impartial review of our denial if one is legally required. By law, we can have one 30-day extension of the time for us to give you access or photocopies if we sent you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to your optometrist at the address shown at the beginning of this notice.
• 4. You can ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30-day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request including your reasons for the amendment to the optometrist at the address shown at the beginning of this notice.
• 5. You can get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want) except disclosures for purposes of treatment, payment of health care operations, disclosures made in accordance with an authorization signed by you, and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30-day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the address show at the beginning of this notice.
• 6. Upon your request you may receive an electronic copy of the information contained in your electronic health record after you sign a release.
• 7. For those who pay out of pocket for services, you may instruct us not to share information about treatment with your insurance company in writing.

Our Notice of Privacy Practices

By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time in compliance with and as allowed by law. If we change this notice, the new privacy practices will apply to your health information that we already have, as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office and have copies available for you if you choose to have a copy.

Complaints

If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U. S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to your optometrist at the address shown at the beginning of this notice. If you prefer, you can discuss your complaint in person or by phone.

For More Information

If you want more information about our privacy practices, call or visit your optometrist at the address or phone number shown at the beginning of this notice.

Submit Data

Please read the following and initial/check that you understand:

• 1. I agree that I have been offered or have received the Notice of Privacy Practice.
• 2. I authorize the release of any medical or other information necessary to process insurance claims.
• 3. I know that contact lens fitting/evaluations are NOT always covered by insurance or vision benefits.
• 4. I certify that I will bear full responsibility for payment of charges not covered by insurance or vision benefits.
• 5. I authorize payment of medical or vision benefits to the physician for services rendered.
Initial and Date: I understand agree to the above policies