Online Patient Form

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Demographics


Patient Information
Title First Last MI Suffix Nickname Pronoun
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian Drivers License #
Emergency Contact: Emergency Contact Phone:
Gender Identity
Pronoun



Primary

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name: Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name: Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision Plan

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name: Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Vision

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name: Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Other

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name: Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:


It is your responsibility to know the terms and limitation of your policies. Failure to inform us of all of your insurance information may result in a denial of benefits and payment in full being owed by you. Please provide us with all of your insurance information. Your carrier is required to respond to our claim submission within 30 days. If we receive no response from your insurance company we may ask you to contact your insurance company or remit payment yourself and seek reimbursement from your insurance company.

We are currently not providers of HMO plans; if you have an HMO plan for medical visits, you are responsible for all fees at the time of your visit. Medical insurance and vision plans are very different in their terms of service and their coverage. We are unable to determine which, if any, can be billed until after the examination is completed.

When a medical condition is present (diabetes, high blood pressure, dry eyes, red eyes, allergies, etc.) it is necessary to file the claim with your major medical carrier. Vision plans do not typically cover medical problems, just as medical insurance does not cover routine glasses and contact lens exams. We are often unable to bill your vision plan for the glasses/contact lens portion of your exam on the same day we bill your medical insurance for management of your medical eye problem. Our office does not make these policies, they are defined by the insurance carriers themselves. We will need copies of your insurance cards and a photo ID.

By signing below, you attest the information listed above is true and that you have read and understand the financial policies of this office listed on this form. If you are using insurance and are denied any part of your claim, you agree to pay any outstanding balance. Please provide your insurance card(s) and a valid form of picture identification with this form at check in.

Patient Signature (OR Parent/Guardian if under 18): Date:



Financial Responsibility Statement & Acknowledgement of Office Policies

Financial Policy: Payment is expected at time service is rendered and before orders are placed. By signing you agree to be held liable for all expenses, costs and reasonable court, attorney and collection agency fees for any delinquent balance. Any check returned unpaid will incur a fee of $25 applicable under state law. A collection service fee will be assessed for any unpaid balances after 30 days of initial notice of balance due. A $25.00 service fee will be assessed for failure to pay your copay at the time of service. Our office may assess an administrative fee for completion of any outside paperwork, forms and chart reviews requested by you. A cancellation fee may be assessed for any appointment missed without at least 24 hours prior notice; Saturday appointments require at least 48 hours prior notice cancellation.

To our patients WITH Vision/Medical benefits: : It is your responsibility to know your coverage and co-pay amounts. Please be aware, unless your insurance plan has specific benefits for contact lens fittings, you will be expected to pay that amount along with your co-pay and any other non-covered services. Any out of pocket expenses collected from you at the time of service are estimates only, your insurance will determine your final out of pocket costs. We are currently not providers of HMO plans; if you have an HMO plan for medical visits, you are responsible for all fees at the time of your visit.
In the event that your insurance company determines that you are not eligible at the time of service, or makes a determination that you are eligible for a reduced level of coverage, by signing this statement you hereby agree to be financially responsible for any and all charges incurred by you and not paid by the insurance plan, and any additional collection fees necessary to collect all amounts due. Be aware that any pre-authorizations received by our office are not in any way a guarantee of payment from your insurance company. After we receive your plan sponsor’s response any and all remaining balances will be due within 30 days. If we do not receive a response from your insurance company within 90 days, we will bill you for the balance due in full. Due to the time limit restrictions imposed by many insurance companies, failure to supply us with the correct insurance information may result in payment in full being owed by you.

Glasses Recheck Policy: This office will recheck any prescription one time at no cost within 60 days of the date on which the prescription was determined. If you were told at the time of the exam that your glasses will need to be altered for varying medical reasons within the 60-day period this recheck policy does not apply and you may be charged a fee. You must be able to furnish the glasses/contacts that you had filled with the aforementioned prescription if not filled through our office. A fee of $25 to confirm the parameters of a prescription pair of glasses not purchased in our office or online store may apply. Other restrictions may apply, ask an associate for details. After 60 days a fee of $45 will be incurred for any recheck. Rechecks will not be performed 6 months from original exam date and a new exam will be necessary.

Glasses Remake Policy and Frame and Lens Warranty: This office will remake prescription glasses once within 60 days of pickup at no charge to the patient in cases of prescription change. Any remakes required beyond the initial remake can and will result in fees for the lenses and any treatments charged at 50% of our usual and customary fees. Frames purchased from our office have a 1-year manufacturer defect warranty and do not cover acts of abuse. Lenses with a scratch treatment have a 1- year warranty depending on the type of scratch treatment purchased which covers wear and tear scratches but not acts of abuse. The replacement warranty fee is $50 at time of use. Neither of our warranties for frames or lenses cover loss or theft. If you used insurance to purchase your glasses your warranty changes from our standard office warranty to your insurance company’s warranty.

Refund Policy: All orders are final when placed. No refunds are given on custom-made prescription items. If you are unhappy with your glasses for any reason, please bring them back to us so we may change them to meet your expectations. Any opened contact lens boxes may not be returned. Refunds will not be given for clincial services provided.

Appointment Cancellation Policy: This office requires 24-hour notification of your appointment cancellation. Cancellations, no shows and late arrivals (15 minutes) will take away an important appointment time slot for someone who needed the appointment and drain unnecessary resources. Any cancellation within 24 hours of your appointment will incur a fee of $50. Saturday appointments require at least 48 hours prior notice cancellation.

Patient Portal: Partners Pacific Optometry utilizes a Patient Portal. This portal allows patients to electronically access spectacle and contact lens prescriptions. By signing this form, I hereby request and agree my eyeglasses and contact lens prescription may be uploaded to the Patient Portal, so that I may have access to them electronically.

Privacy Policy, HIPAA and Your Records: This office follows HIPAA guidelines concerning the privacy of your medical information. We will not release any of your information to anyone without your written prior authorization with the exception of other health professionals and your insurance company as outlined in HIPAA if applicable. A copy of the HIPAA guidelines is available upon request. Under California law your records will be maintained for a minimum of seven years.

By signing below, you understand the financial statement and policies of Partners Pacific Optometry listed above.

Signature: Date:

Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Chief Complaint:
Medications you are taking:
Vitamins/Supplements:

Primary Care Physician

Family Medical History Unknown family history

Condition Patient Mother Father Sibling No Describe
Diabetes
Hypertension
Thyroid
Vascular Disease
Cancer

Pregnant/Nursing Last Physical Exam

Review Of Systems


Major Injury/Surgery
Other MHx
General
ENT
CVD
Pulm
Gen/Ur
GI
Endoc
Mus/Skel
Skin
Neuro
Psych
Hem/Lym
Immune

Condition Patient Mother Father Sibling No Describe
Glaucoma
Macular Degeneration
Retinal Detachment
Cataract
Amblyopia/Strabismus

Ocular Injury/Surgery/Lasik
Other History
Rx/Over The Counter Drops

Smoking History
Recently quit
Alcohol
Race
Language

Lifestyle Questionnaire:

Do you get eyestrain or headaches when using a computer? Y N
Are you required to wear safety glasses at work? Y N
Do you participate in shooting sports? Y N
Do you golf, run, or participate in outdoor activities? Y N
Do you participate in water sports (i.e. skiing, surfing, fishing)? Y N
Do you have problems with glare at night? Y N
Do you have problems with glare during the day? Y N
Do you have problems with your glasses fogging over? Y N
Do you have problems with cleaning your glasses? Y N
How many hours a day do you spend on the computer (working, studying, gaming)?

By signing below, you attest the provided on this form is accurate and true.
Patient (Guardian if under 18) Signature:



Patient Signatures:

Contact Lens Fitting Information & Agreement

Contact lenses are FDA Class I medical devices that have the potential for serious complications in not used and fitted properly. For that reason, the standard of care and the requirements for the California State Board of Optometry require an annual examination for renewal of the contact lens prescription.

Patient Eligibility: You must have had a general eye exam within three months prior to obtaining a contact lens fitting. If you had an eye exam outside of Partners Pacific Optometry, your exam records need to be forwarded to us. Patients under the age of 12 years old will only be fitted in daily disposable replacement contact lenses.

Fitting Service Includes: In addition to general eye health assessment, the doctor will assess issues related to contacts such as abnormal blood vessel growth, corneal damage, chronic inflammation, hygiene, discomfort, and poor surface compatibility leading to dry eyes, in addition to any vision changes.

Fitting fees: The estimated fee for these services range between $75.00 and $140.00. These fees will cover any contact lens related follow ups for two months. If you cannot complete the fitting procedure in the allotted time due to missed follow up appointments, there will be an additional $40.00 charge per visit beyond the global time two month period. First time contact lens wearer fees require a $50 training fee to include insertion and removal of contact lenses training and instructions on proper contact lens care. This training fee covers no more than 4 training sessions or when determined by the doctor the patient is not a good candidate to wear contact lenses.

Cost of Lenses: The cost of contact lenses is not included in the fitting fee and is determined by the type of lens prescribed by the doctor. It is often difficult to predict the cost of materials before the fit is finalized. We are happy to review the estimated cost of your lens before beginning any fitting process if you request to do so.

Refund: In general, there is no refund for professional contact lens fitting fees. Contact lens materials cannot be refunded after 30 days. Lenses in opened boxes or damaged (i.e. writing on boxes or crushed boxes) may not be returned.

Insurance: Most medical insurance plans do not cover contact lenses. Vision plans may have contact lens benefits eligibility towards the contact fitting fees and/or materials. Our staff can help you check your eligibility.

Contact Lens Prescription:A contact lens prescription will be released to patients only after the fitting, including follow-up care, has been completed. Contact lens prescriptions by law expire one year from the date we initiate the contact lens fitting. The patient's final contact lens prescription will be available in digital form on Dr. Contact Lens, our office's online ordering platform.

By signing, I acknowledge that I understand the policies regarding the contact lens evaluation and agree to the associated lens fees. I understand these fees are nonrefundable once the services have been initiated. I understand that these fees are an estimate and are subject to changes based on the doctor's final assessment. I also understand that improper usage of contact lenses as prescribed can lead to vision loss and permanent eye damage. I understand if an infection is present, I will need to be treated under my medical insurance prior to being refit with contact lenses.

Signature: Date:



NEW PATIENT Contact Lens Fitting Information & Agreement

Contact lenses are FDA Class I medical devices that have the potential for serious complications if not used and fitted properly. For that reason, the standard of care and the requirements for the California State Board of Optometry require an annual examination for renewal of the contact lens prescription



Patient Eligibility: You must have had a general eye exam within three months prior to obtaining a contact lens fitting. If you had an eye exam outside of Partners Pacific Optometry, your exam records need to be forwarded to us. Patients under the age of 12 years old will only be fitted in daily disposable replacement contact lenses.


Fitting Service Includes: In addition to general eye health assessment, the doctor will assess issues related to contacts such as abnormal blood vessel growth, corneal damage, chronic inflammation, hygiene, discomfort, and poor surface compatibility leading to dry eyes, in addition to any vision changes.


Fitting fees: The estimated fee for these services range between $75.00 and $140.00 These fees will cover any contact lens related follow ups for two months. If you cannot complete the fitting procedure in the allotted time due to missed follow up appointments, there will be an additional $40.00 charge per visit beyond the global time two month period. . First time contact lens wearer fees require a $50.00 training fee to include insertion and removal of contact lenses training and instructions on proper contact lens care. This training fee covers no more than 4 training sessions or when determined by the doctor the patient is not a good candidate to wear contact lenses.


Cost of Lenses: The cost of contact lenses is not included in the fitting fee and is determined by the type of lens prescribed by the doctor. It is often difficult to predict the cost of materials before the fit is finalized. We are happy to review the estimated cost of your lens before beginning any fitting process if you request to do so.


Refund: In general, there is no refund for professional contact lens fitting fees. Contact lens materials cannot be refunded after 30 days. Lenses in opened boxes or damaged (i.e. writing on boxes or crushed boxes) may not be returned.


Insurance: Most medical insurance plans do not cover contact lenses. Vision plans may have contact lens benefits eligibility towards the contact fitting fees and/or materials. Our staff can help you check your eligibility.


Contact Lens Prescription: A contact lens prescription will be released to patients only after the fitting, including follow-up care, has been completed. Contact lens prescriptions by law expire one year from the date we initiate the contact lens fitting. The patient's final contact lens prescription will be available in digital form on Dr. Contact Lens, our office's online ordering platform.


By signing, I acknowledge that I understand the policies regarding the contact lens evaluation and agree to the associated lens fees. I understand these fees are nonrefundable once the services have been initiated. I understand that these fees are an estimate and are subject to changes based on the doctor's final assessment. I also understand that improper usage of contact lenses as prescribed can lead to vision loss and permanent eye damage. I understand if an infection is present, I will need to be treated under my medical insurance prior to being refit with contact lenses.

Signature: Date:


Eye Wellness Digital Retinal Exams

Partners Pacific Optometry is pleased to offer you and your family the most highly advanced state of the art technology available in eye disease detection: the Optomap Digital Retinal Imaging & Optovue Wellness Exam.

Our Doctors are concerned about retinal diseases such as macular degeneration, glaucoma, retinal detachments, and diabetic retinopathy, all which can lead to partial loss of vision or blindness. Additionally, systemic diseases such as diabetes and high blood pressure can be detected with a retinal examination. Eye exam with retinal evaluations can help you safeguard both your eyesight and general health.

The Optomap Digital Retinal Imaging allows us to scan 85% of the retina to thoroughly evaluate your internal eye health with dramatically improved precision. The Optovue Wellness Exam is a quick and non-invasive scan of your eye that lets the doctor see the individual layers of your retina to aid in the diagnosis of sight-threatening eye disease. Early detection is crucial.

The doctor strongly recommends that ALL patients have this procedure performed every year. It is especially important for people who have:
* Headaches
* Diabetes
* High Blood Pressure
* High Cholesterol
* Family history of glaucoma, blindness, or macular degeneration
* Family history of diabetes or high blood pressure

With an annual Wellness Imaging, our doctors can track your eye health for concerns, perform annual comparisons, and initiate treatments sooner. Medical and Vision insurances do not pay for routine screening photos. As a result, there is a $45.00 fee for this procedure. (Please advise staff if you have a history of epilepsy.)
These Retinal Images augments a dilated exam by creating a permanent documentation of the retina.

I am a NEW patient and understand retinal imaging is mandatory. I understand there is a $45 fee for this procedure because some medical and vision insurances do not pay for routine photos.

Returning patient: I choose to have the Retinal Wellness Imaging. I understand that based on the doctor's assessment of the retinal scan and examination, dilation may still be recommended. I understand there is a $45.00 fee for this procedure because some medical and vision insurances do not pay for routine photos.**

Returning patient: I choose to be dilated today. I understand that after dilation, my vision will be slightly blurry when reading, and I might be sensitive for 3-4 hours.



*** Some medical and vision plans cover retinal imaging. Patient is responsible for the contracted co-pay of retinal imaging. Co-pays vary by insurance plans and contracts.

Signature: Date:
Relationship if signed by personal representative or patient):


This office requires 24 hour notification of your appointment cancellation. Cancellations, no shows and late arrivals (15 minutes) will take away an important appointment time slot for someone who needed the appointment and drain unnecessary resources. Any cancellation within 24 hours of your appointment will incur a fee of $50.

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