Online Patient Forms

Patient information

First name

*This field is required

Last name

*This field is required

Nickname

Birth Sex

Male Female

Address

*This field is required

Apt/Suite #

City

*This field is required

State

*This field is required

Zip Code

Cell Phone

Home Phone

Preferred Contact Method

Birthday

*This field is required

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Marital Status

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Primary Vision Insurance

Insurance Information

Family Eye Care accepts most medical ppo plans, and EyeMed + VSP vision plans. Please contact a staff member with any concerns about insurances accepted.

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Primary Medical Insurance

Insurance Information

Family Eye Care accepts most medical ppo plans, and EyeMed + VSP vision plans. Please contact a staff member with any concerns about insurances accepted.

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Name:

Relationship To Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Please choose from the menu options or select the option to type in your own text. Thank you!

Medical History

Please choose from the menu options

Eye History

Reason for Visit

Do you currently have any of these eye symptoms?

*This field is required

Do you currently take any of these medications?

*This field is required

Have you had any eye surgeries? Please describe

Last Eye Exam

Last Appointment Type

By Doctor

Primary Vision Correction

*This field is required

Do you:

Have Backup Glasses?

Want New Glasses?

Contact Lens Wearers only:

Type of Contacts worn in the past

Cleaner

Disposal

Wear Time

Medical History:

Medications - Type None if no medications are taken.

*This field is required

No Medications

Over the Counter Medications - Type None if no medications are taken.

*This field is required

Vitamins - Type None if no medications are taken.

*This field is required

Drug allergies - Type None if no medications are taken.

*This field is required

Please Describe any Injuries or Surgeries you have had

*This field is required

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Recent Tetanus Shot

Recent Flu Immunization

Do you have any of these medical conditions?

Diabetes

*This field is required

Hypertension

*This field is required

High Cholesterol

*This field is required

Thyroid Conditions

*This field is required

Heart Conditions

*This field is required

Cancer

*This field is required

Year Diabetes Diagnosed

Other

Family Medical History

Unknown Family History

Does anyone in your family have any of these medical conditions?

Hypertension

*This field is required

Diabetes

*This field is required

Thyroid

*This field is required

Cancer

*This field is required

High Cholesterol

*This field is required

Heart Conditions

*This field is required

Other

Family Eye History

Does anyone in your family have any of these eye conditions?

Macular Degen

*This field is required

Glaucoma

*This field is required

Retinal Detach

*This field is required

Blindness

*This field is required

Cataracts

*This field is required

Lazy/Crossed Eye

*This field is required

Review Of Systems

General

*This field is required

Skin

*This field is required

Ear/Nose/Throat

*This field is required

Respiratory

*This field is required

Musculoskeletal

*This field is required

Psychiatric

*This field is required

Endocrine

*This field is required

Blood/Lymph

*This field is required

Neurological

*This field is required

Immune

*This field is required

Genitourinary

*This field is required

Gastrointestinal

*This field is required

Cardiovascular

*This field is required

Social History

Hobbies

Smoking Status

*This field is required

Type

How long

Alcohol Use

*This field is required

Type

How long

Marijuana

*This field is required

Type

How long

Race

*This field is required

Ethnicity

*This field is required

Preferred Language

*This field is required

STD

*This field is required

Policies, Consent, Submit Data

Billing Policy
Because patients often have both medical and vision insurance, it is important to understand the differences.

Vision insurance does not cover medical eye problems, just as most medical insurance does not cover routine vision problems.

VISION INSURANCE
• Covers routine eye examinations only • Helps to pay for glasses or contact lenses

MEDICAL INSURANCE
Covers exams where any medical condition that can affect the eyes is evaluated. Examples of these conditions include:

• Diabetes

• Infections

• High blood pressure

• Dry eyes

• Taking high risk medications

• Allergies

• Eye diseases

• Cataracts

• Lazy eye

• Crossed eye

After your examination, the doctor will determine to which insurance the exam will be fi led. Glasses and/or contact lenses might still be fi led to your vision insurance if the exam is fi led to your medical insurance. We try to be a provider on all major carriers. If we are a provider for your insurance we will fi le a claim to your primary insurance carrier. However, in the event we are not on your providerâs panel, we will provide an itemized receipt so you may file the claim for yourself.

If you have a secondary insurance, and the co-pays or co-insurance is not automatically transferred, you will receive a statement, and you must fi le the secondary claim. The balance on that statement is your responsibility. Family Eye Care cannot provide a secondary claim filing service.

All sales are final. No refunds on services. Accounts 30 days past due are charged a 1.5% monthly finance charge.

The responsible party shall be liable for all collection costs, including but not limited to, attorney fees, and court costs.

I understand the information above and authorize Family Eye Care to fi le a claim with my insurance.

Patient Signature

Date

Authorization of Release of Information to Family Members

Many of our patients allow family members such as spouse, parents, or others to call and request medical or billing information. Under the requirements of HIPAA we are not allowed to give this information to anyone without patient's consent. If you wish to have your medical or billing information released to others you must sign this form. Signing this form will give information to only people listed below.

I authorize Family Eye Care to release my medical and/or billing information to the following:

Relationship To Patient:

Patient Information
I understand I have the right to revoke this authorization at any time, and that I have the right to inspect or copy the protected health information to be disclosed.

I understand that information disclosed to any above recipient is no longer protected by federal or state law and may be subject to redisclosure by the above recipient.

You have the right to revoke this consent in writing.

Patient Signature

Date

HIPAA PRIVACY
Acknowledgement of Receipt of Privacy Notice

By signing this Acknowledgement of Receipt of Privacy Practices Notice, I acknowledge and agree that I have reviewed a copy of the Notice of Privacy Practices, and I can request a copy to keep for my records on the date indicated below.

I understand Family Eye Care of Woodstock, LTD. & Lake Geneva, S.C., may use and disclose necessary personal health information (for example, my name, address, subscriber identification number, eye exam information and/or type of products provided) to another party to permit Family Eye Care of Woodstock, LTD. & Lake Geneva, S.C., to perform its administrative duties, provide me with eye care service and products, process my benefit claims and communicate with me regarding services provided by Family Eye Care of Woodstock, LTD. & Lake Geneva, S.C., (for example, mailings and phone calls for exam reminders or information about services/products provided by Family Eye Care of Woodstock, LTD. & Lake Geneva, S.C.)

I can be assured that Family Eye Care of Woodstock, LTD. & Lake Geneva, S.C., does not sell my personal health information of any kind to a third party for such party's own use. I acknowledge and agree that Family Eye Care of Woodstock, LTD. & Lake Geneva, S.C., may submit my insurance claims to my plan sponsor or health plan to receive reimbursement directly for the services and products I receive.

Patient Signature or Patient's Legal Representation

Date