This form provides our clinic with demographic information about you that we are required to keep on file in your medical record. This form also provides us with the information necessary to verify your insurance eligibility and to bill your health care insurance for eye care services when indicated. To complete this form, please fill out the form, print, and present to the front desk at the time of check-in. If this is your first visit to the Eye Care Center, we ask that you complete this form. It is not necessary for established patients to complete this form. This form is not necessary if you have filled out the Web Registration form above.
This form records details about your general health, current medications you are taking, medication allergies and previous eye history. This is essential information for our doctors to provide comprehensive eye care and to understand how this eye care integrates with the health of the rest of your body. This can be detailed and complex information and will be much easier for you to locate and document in your home rather than at our clinic. To complete this form, please fill out the form, print, and present to the front desk at the time of check-in. We ask that new and established patients bring this completed form to your appointment. This form is not necessary if you have filled out the Web Registration form above.
The Federal Health Information Portability and Accountability Act of 1996 (HIPAA) requires that our clinic inform you of how we use, disclose and maintain the privacy of all the information we collect about you as our patient. We ask that you read this document, acknowledge that you have read it by signing the document and bring the form to your appointment. Please download a second copy if you wish to keep a hard copy for your own records. Federal law requires that you read and sign this document one time. If you have previously completed and signed this document, you are not required to do so again.
RELEASE OF PATIENT RECORDS
This form is to be used if you would like your past provider to release your medical and/or prescription information to the Eye Care Center, or in the event that you would like the Eye Care Center to release your medical record and/or prescription information to another provider. If this is your first visit to the Eye Care Center, we ask that you complete this form if you have had an eye exam over the past three years