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Patient Welcome Form

  • Date Format: MM slash DD slash YYYY
  • for appointment reminders and notification of glasses and contacts
  • Health Insurance Portability and Accountability Act-HIPAA

  • Health Insurance Portability and Accountability Act-HIPAA
    We respect the legal obligation to keep your health information private. The most common reason why we use or disclose your health information is for treatment, payment, or health care operations. If you would like a copy of our Notice of Privacy Practice please let the front desk know. By signing below it means that you are aware of our privacy practices and that you have been given the opportunity to obtain a copy of our policy.
  • Date Format: MM slash DD slash YYYY
  • Payment Information

  • Payment Information
    Payment is expected at the time services are rendered. Accounts left unpaid after 120 days will automatically be turned over for collections along with a $35 service charge. I understand that I will receive a statement after 30 days if the insurance has not paid. I further understand that I am responsible for the total amount due or any amount unpaid by the insurance. Any denial or dispute of payment by my insurance company is my responsibility. If insurance is being billed by our office, this signature serves as your “signature on file”.
  • Date Format: MM slash DD slash YYYY
  • Authorization for Release of Information

  • Authorization for Release of Information
    Many of our patients allow family members to call and request medical or billing information. Under the requirements of HIPAA we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical or billing information released to a family member, you must list the family/friend and sign below.
    I authorize Eyecare Associates to release my medical and/or billing information to the individuals listed below. I understand I have the right to revoke this authorization at any time and that I have the right to inspect or receive a copy of the PHI to be disclosed.
  • Date Format: MM slash DD slash YYYY

  • Date Format: MM slash DD slash YYYY
  • Please list
  • SelfFamily Member(s)
    Macular Degeneration
    Diabetic Eye Disease
    Retinal Detachments
    Eye Turns
    Eye Surgeries
    Eye Allergies
    Eye Injuries
    Eye Infections

  • Are you currently pregnant or nursing?
  • SelfFamily Member(s)
    Digestive System
    Blood / Lymph
    Ear / Nose / Throat
    Allergies / Immune system
    Mental / Psychiatric
    Musculoskeletal (arthritis, joint pain, etc.)
    Respiratory (asthma, emphysema, etc.)
    Nervous System (headaches, MS, seizures, etc.)
    Endocrine (thyroid, diabetes, etc.)
    Cardiovascular (cholesterol, high blood pressure, etc.)
    Genitourinary (kidney, bladder, etc.)
  • Thank you and welcome to our practice!