Last Name: Click here to enter text.____First Name: Click here to enter text.___ M.I. : Click here to enter text.
Social Security # Click here to enter text.___Date of Birth:Click here to enter a date._Sex: ☐Male / ☐Female
Address: Click here to enter text.City: Click here to enter text.State: Click here to enter text.Zip: Click here to enter text.
*E-Mail Address: Click here to enter text.D.L. #: Click here to enter text.
Home_Click here to enter text._Work_Click here to enter text.___Cell___Click here to enter text.
*Primary Care Physician
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*PERSON RESPONSIBLE FOR THE BILL (ONLY APPLICABLE IF OTHER THAN SELF)
Last Name__Click here to enter text.__First Name__Click here to enter text. M.I.Click here to enter text.
Address_Click here to enter text._ City __Click here to enter text.__State__Click here to enter text.___ Zip Click here to enter text.
Relationship to Patient _Click here to enter text.__
*INSURANCE INFORMATION (PLEASE LIST POLICY HOLDER IF OTHER THAN SELF)
*1STInsurance: _Click here to enter text. Policy # ___Click here to enter text._
Policy Holder _Click here to enter text.__ Relationship_Click here to enter text.__ Date of Birth _Click here to enter a date.
Social Security # _Click here to enter text.EmployerClick here to enter text.
*2ND Insurance: _Click here to enter text.____Policy # ___Click here to enter text.
Policy Holder _Click here to enter text._ Relationship___Click here to enter text.__ Date of Birth __Click here to enter a date.
Social Security # _Click here to enter text.Employer Click here to enter text.
*ADDITIONAL INFORMATION:
Emergency Contact_Click here to enter text.__Phone #__Click here to enter text._ Relationship Click here to enter text.
How Did You Hear About EyeCare Associates?
1) Friend/Family (Name) _Click here to enter text.__ 2) TV _Choose an item._ 3) Radio _____ 4) Newspaper ______
CONSENT TO TREATMENT: I voluntarily consent to receive medical and health care services provided by EyeCareAssociates of Texas, P.A. physicians, employees and such associates, assistants, and other health care providers asmy physicians deem necessary. I understand that such services may include diagnostic procedures, examinationsand treatment. I acknowledge that no warranty or guarantee has been made to me as to result or cure.I understand that this consent to treatment will be valid and remain in effect as long as I attend EyeCare Associatesof Texas, P.A. Clinics, unless revoked by me in writing.
RELEASE OF INFORMATION/NOTICE OF PRIVACY POLICIES: I understand my signature authorizes release of confidential medical informationnecessary to pay claims to Medicare or other health insurers.I understand that I may revoke this authorization for the release of information at any time, by providing written noticeto EyeCare Associates of Texas, P.A., except to the extent that action has been taken in reliance on it. I have been offered a copy of EyeCare Associates of Texas, P.A. Notice of Privacy Policies, and understand the contents. If I have any restrictions concerning the use of my personal medical information, I will inform EyeCare Associates of Texas, P.A. in writing. I release and agree to hold harmless EyeCare Associates of Texas, P.A. and its agents,representatives, and employees from any and all liability associated with the release of confidential patient informationin accordance with this authorization.I understand EyeCare Associates of Texas, P.A. cannot be responsible for use or re-disclosure of information by thirdparties.
FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF BENEFITS: In consideration for receiving medical or healthcare services, I hereby assign my right, title and interest in all insurance, Medicare/Medicaid, or other third partypayer benefits for medical or health care services payable to me, payable to the providers of EyeCare Associates ofTexas, P.A. I also authorize direct payments to be made by Medicare/Medicaid and/or my insurance company orother third party payer, up to the total amount of my medical and health care charges, to the providers of EyeCareAssociates of Texas, P.A. I certify that the information I have provided in connection with any application for paymentby third party payers, including Medicare/Medicaid, is correct.I agree to pay all charges for medical and health care services not covered by or which exceed the estimated amountto be paid or actually paid by Medicare/Medicaid, my insurance company, or other third party payor and agree tomake payment as requested by EyeCare Associates of Texas, P.A.
___Click here to enter text.______
Patient/Other Legally Authorized Signee
___Click here to enter text.______Click here to enter a date._____
Printed Name and Relationship to PatientDate
CONSENT FOR TREATMENT OF MINORS:I, the parent or legal guardian of the above mentioned minor, consent to any necessary medical treatment performed during examination including dilation. This authorization is valid until revoked by me in writing.
Click here to enter text.Click here to enter a date.
Signature of Parent or GuardianDate
MEDICAL HISTORY
Please state primary reason for your visit today:Click here to enter text.
Current and Past Eye History:
Do you currently have or been diagnosed with any of the following?:
Macular Degeneration☐Yes ☐NoGlaucoma☐Yes ☐No
Cataracts☐Yes ☐NoRetinal Detachment☐Yes ☐No
Strabismus☐Yes ☐NoCorneal Disease☐Yes ☐No
Trauma☐Yes ☐NoBlindness☐Yes ☐No
Loss of Side Vision☐Yes ☐NoDouble Vision☐Yes ☐No
Red Eye/Discharge☐Yes ☐NoPain☐Yes ☐No
Glare/Light Sensitivity☐Yes ☐NoDry Eye/Tearing☐Yes ☐No
Eye Drops Currently In Use: Yes No
List Names and Dose:Click here to enter text.
Current and Past Medical History:
Do you currently have or been diagnosed with any of the following?:
Heart Disease ☐Yes ☐No Asthma ☐Yes ☐No
Diabetes ☐Yes ☐No Emphysema ☐Yes ☐No
Hypertension ☐Yes ☐No High Cholesterol ☐Yes ☐No
Thyroid Disease ☐Yes ☐No HIV ☐Yes ☐No
Rheumatoid Arthritis ☐Yes ☐No Lupus ☐Yes ☐No
Sjogrens ☐Yes ☐No Hepatitis ☐Yes ☐No
Current Medications (other than eye drops):☐Yes ☐No
List Names:Click here to enter text.
Medication Allergies (including eye drops):☐Yes ☐No
List Names and Reaction:Click here to enter text.
Current and Past Family History:
Have any immediate family members been diagnosed with any of the following?:
Macular Degeneration☐Yes ☐NoGlaucoma☐Yes ☐No
Cataracts☐Yes ☐NoRetinal Detachment☐Yes ☐No
Strabismus☐Yes ☐NoCorneal Disease☐Yes ☐No
Heart Disease ☐Yes ☐NDiabetes☐Yes ☐No
Social History:
Smoke☐Yes ☐NoDrink Alcohol☐Yes ☐No
Caffeine ☐Yes ☐NoRecreational Drugs☐Yes ☐No
Surgical History :
List any major surgical procedures and dateClick here to enter text.
Review of Systems:
Do you presently have problems in any of the following areas? (if YES give explanation)
Ears, Nose, Mouth, Throat☐Yes ☐NoClick here to enter text.
Cardiovascular (Chest Pain)☐Yes ☐NoClick here to enter text.
Respiratory (Cough)☐Yes ☐NoClick here to enter text.
Gastrointestinal (Ulcers)☐Yes ☐NoClick here to enter text.
Hematologic (Anemia)☐Yes ☐NoClick here to enter text.
Musculoskeletal (Joint Pain)☐Yes ☐NoClick here to enter text.
Integumentary (Skin/Breast)☐Yes ☐NoClick here to enter text.
Neurological (Tingling,Numbness)☐Yes ☐NoClick here to enter text.
Refraction Fee PolicyA Refraction determines your prescription.It is the measurement which helps to determine the corrective lens power to be prescribed to provide the sharpest, clearest and most comfortable vision.
The refraction is necessary for these important things:
- A glasses or contact lens prescription. If you want an updated glasses or contact lens prescription we must have a refraction performed today.
(Either prescription is only valid for one year from the date it was issued)
- Determining if you qualify for cataract surgery. If you are interested or think you are ready for cataract surgery we must have a refraction performed today.
- Determining the cause of any decreased vision.
The refraction test, also termed vision test, is an examination that tests an individual’s ability to see an object at a specific distance. The test involves looking through a device called a phoropter to read letters or recognize symbols on a wall chart through lenses of differing strength which are contained within the device. (During this process, the technician will ask you “Which is better…one or two?”). This test is performed as part of a normal eye examination to determine whether an individual has normal vision. It is also used to determine the prescription for eyeglasses or contact lenses.
Unfortunately, Medicare considers this a routine test and therefore does not approve it making it a non-covered service. Since Medicare doesn’t cover it, commercial insurance companies follow suit and also consider it a non-covered service and payable by the patient.The fee for this service is $35.
☐ Yes, I wish to have a refraction performed today and understand I will owe $35 for this service.
☐No, I do not want to have the refraction performed today.
Click here to enter text.Click here to enter a date.
SignatureDate
EyeCare Associates of Texas, P.A.
CONSENT FORM
DISCLOSURE OF PROTECTED HEALTH INFORMATION
TO ADDITIONAL PARTIES
AUTHORIZATION TO SHARE HEALTH CARE INFORMATION WITH FRIENDS & FAMILY
EyeCare Associates of Texas, P.A. is bound by law to share details of your care with you (or legal guardian) and only you (see exception under medical release.) If in your particular situation it is desirable to share the details with others (other than those described in the Privacy Practices), then you must give specific permission. Example: Adult family member is permitted to access care information about a senior parent. If you desire to give such permission, please complete this portion of the form.
I permit the following individuals to access my healthcare information:
Name / RelationshipClick here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. /
I understand that the release of information may be electronic, written or verbal and that this consent form will remain in effect until a written request for revocation is received by our office. EyeCare Associates of Texas, P.A. reserves the right, at its discretion, to limit the disclosure of medical information to additional parties (such as family members) unless we have a signed copy of this form on file.
___Click here to enter text.______Click here to enter a date._____
Signature Date
RECEIPT OF NOTICE OF PRIVACY PRACTICES
EyeCare Associates of Texas, P.A.
A Notice of Privacy Practices (NPP) is available to all patients. This NPP identifies 1) how medical information about you may be used or disclosed; 2) your rights to access your medical information, amend your medical information, request an accounting of disclosures of your medical information, and request additional restrictions on our uses and disclosures of that information; 3) your rights to complain if you believe your privacy rights have been violated; and 4) our responsibilities for maintaining the privacy of your medical information.
I certify that I have read the foregoing, and that a copy of the NPP (Revision 03-21-2016) has been made available to me. I attest that I am the patient, or the patient’s personal representative (parent, guardian, caretaker etc.)
Click here to enter text.
Signature of Patient
Click here to enter a date.
Date
OR
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Signature of Representative
Click here to enter text.Click here to enter a date.
Relationship to Patient Date
EyeCare Associates of Texas, P.A.
Office Policies and Procedures
Insurance – Insurance card and driver’s license must be presented prior to each office visit in order to utilize benefits. Please notify our office if there is a change in your insurance plan or coverage. We file claims as a courtesy to our patients and are only responsible for filing claims to contracted insurance carriers. Any dispute for unpaid charges from the insurance company will be billed directly to the patient and due upon receipt of a statement from our office.
If you plan to utilize your routine benefits (VSP/EyeMed/AAFES) please notify us at the time of check in so that your claims may be processed correctly. If you fail to notify us we cannot re-file the claim at a later date. If your insurance company requires you to have a referral for your visit you must contact your primary care doctor at least 7 days in advance of your appointment and call our office 1 day prior to your appointment to be sure we have received the necessary documentation.
Paperwork - You are required to update paperwork annually. If you have not been seen by one of our physicians within the last 6 months, or come in with a new problem, you will be asked to update your information. This allows us to keep your medical record up to date so that we may provide quality care.
Payment – Full payment is due at the time services are rendered unless other payment arrangements have been made with our billing department prior to your visit.
Medication Refills – Prescription refill requests are required to be called into your pharmacy at least 5 days prior to running out of your medication to allow adequate time for approval. Refills will only be handled during normal business hours Monday through Friday. Please contact your pharmacy for refill requests.
Appointment Reminders – You will receive a reminder call/text from our office 2 days prior to your scheduled appointment and an email confirmation one week prior if your email is on file. Please confirm your appointment with this system if you are able to do so.
After Hours – Our phone message will provide you with instructions to reach the physician on call. This service is to be utilized in emergency situations only. Refill requests or routine requests for appointments will not be returned until the next business day by a staff member.
NSF Checks – A $25 fee will be added to your account for all returned checks.
Minor Patients - For all services rendered to patients age 17 or younger we will look to the adult accompanying the patient for payment. All minors must have written consent from the parent/guardian in order for us to provide treatment.
Thank you for your understanding and we look forward to providing you quality eye care.
634 Uptown BlvdCedar Hill, TX 75104
Ph 972-637-1300
Fax 1-866-353-7586 / 507 W. Crossland Blvd
Grand Prairie, TX 75052
Ph 972-642-2121
Fax 972-642-9997