PATIENT REGISTRATION FORM

To save time at check in; please fill out this form if you are a NEW patient or have UPDATES.

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Patient Registration Form
Primary Insurance
Additional Insurance
The undersigned hereby authorize the release of any information relating to all claims for my benefits submitted on behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this document authorize my physicians at Eye Physicians of Libertyville to submit claims for benefits, for services rendered or for services to be rendered without obtaining my signature on each and every claim to be submitted for myself and my dependants, and that I will be bound by signature as through the undersign had personally signed the particular claim. I authorize my insurance company to pay and assign directly to Eye Physicians of Libertyville, S.C. all benefits if any, as described in the claims submitted by the physicians for services rendered. I understand I am financially responsible for all charges incurred. I further acknowledge that any benefits when received C., will be credited to my account in accordance with the above assignment.
Health History
Do you currently have or been previously diagnosed with any of the following?
Do you have high blood pressure?
Do you use any illicit drugs?
Do you drink alcohol?
Ocular History
Have you been diagnosed with any of the following eye diseases or conditions?
Have you ever had eye surgery?
Which eye?
Family History
Have any blood relative had any of the following?
Release Form
I hereby give my consent to Eye Physicians of Libertyville S.C. to use or disclose, for the purpose of carrying out treatment, payment, or health care operations, all information contained in the patient record of the person named in the Patient Record filed below.
I acknowledge receipt of the physicians Notice of Privacy Practices. The Notice of Privacy Practices provides detailed information about how the practice may use and disclose my confidential information.
I understand that the physician has reserved a right to change his or her privacy practices that are described in the Notice. I also understand that a copy of any Revised Notice will be provided to me or made available upon request.
I understand that this consent is valid until it is revoked by me. I understand that I may revoke this consent at any time by giving written notice of desire to do so, to the physicians. I also understand that I will not be able to revoke this consent in cases where the physician has already relied on it to use or disclose my health information. Written consent must be sent to the physician's office.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
The Health Insurance Portability & Accountability Act of 1996 ('HIPAA') is a federal program that requires all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept confidential. This act gives you, the patient, significant new rights to understand and control how your health information is used. 'HIPAA' provides penalties for covered entities that misuse personal health information. As required by 'HIPAA', we have prepared that explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.
We may use and disclose your medical records only for each of the following purposed: treatment, payment and health care operations.
Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination. Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment. Healthcare operations includes the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. We may also create and distribute de identified health information by removing all references to individually identifiable information.
We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your information.
You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:
- The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction, If we do agree to a restriction, we must be abide by it unless you agree in writing to remove it. -The right to reasonable requests to receive confidential communication of protected health information from by alternative means or at alternative locations. -The right to inspect and copy your protected health information. -The right to amend your protected health information. -The right to receive an accounting of disclosure of protected health information. -The right to obtain a paper copy of this notice from us upon request.
We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from the office.
Thank you very much for taking time to review how we are carefully using your health information. If you have any questions we want to hear from you. Please acknowledge your receipt of our policy by signing below.
Notice of Privacy Practices
The following person(s) can inquire, pick up records, prescriptions, x-rays, etc, and take messages regarding your health information. (Please include any physicians, friends, or relatives to whom you may allow to take part in caring for your health.)
If you are not available at the time we call you, may we:
Disclose medical information on an answering machine?
It is the patient's responsibility to contact us with any changes to the above information in writing
Leave appointment information on an answering machine?
The Refraction Charge
Refraction is the procedure in which we determine the best corrected visual acuity for each eye for the purposes of medical evaluations or for spectacles, contact lenses, or corrective surgery. For most insurances, including Medicare, there is no provision for coverage of this procedure, and there is no indication that it will likely become a covered service anytime in the near future.
Refraction is necessary to adequately determine visual function and is important in making sure that serious underlying eye problems do not exist. We perform refractions as a part of all of our comprehensive eye evaluations.
We trust that you will understand the need to perform this procedure and we respectfully ask for payment at the time of service.
NOTE: Our refraction fee is currently $45. The fee may not be covered by your plan. In that case, you will be responsible for this fee whenever the doctor checks your eyes for glasses.
I am stating I have read this form (or it has been read to me) and I fully understand that I will be responsible for all the charges relating to the refraction portion of the exam.
Some vision plans may cover the 'refraction fee', but most do not.
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