Patient Welcome Form

Name: Eyecare Associates
Address: 702 W Drake Rd, Bldg B, Fort Collins, CO, 80526, US
Telephone: 970-221-4811
Price range: $000 - $300

Patient Name:
First Middle Last
Date of Birth:
Date Format: MM slash DD slash YYYY
Sex:
- Male
- Female
Social Security #:
Address
Street Address Address Line 2 City State ZIP Code
Home Phone:
Cell Phone:
Work Phone:
Race
- Hispanic
- White
- American Indian
- Asian
- Black/African American
- Native American
Ethnicity
- Hispanic or Latino
- Not Hispanic or Latino (Caucasian)
- Native American
- Arab
- Black/African American
- Native Hawaiian or other Pacific Islander
Preferred Language
- English
- Spanish
- Arabic
- French
Email Address
for appointment reminders and notification of glasses and contacts
Communication Preferences:
- Home Phone
- Cell Phone
- Work Phone
- Email
- Postal
Can we leave a message regarding test results?
- Yes
- No
Employer:
Occupation:
If Minor, Name of Guardian:
First Last
If Married, Spouse’s Name:
First Last
In the event of an emergency whom can we contact?
Name Phone
Whom may we thank for referring you to our office?
- Friend/Family member
- Phone Book
- Search Engine
- Website
- Insurance Listing
- Newspaper
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.
Signature
Date
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”.
Signature
Date
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.
1.
Name Relation to patient
2.
Name Relation to patient
Signature
Date
Date Format: MM slash DD slash YYYY
VISION HISTORY
Date of last eye exam:
Date Format: MM slash DD slash YYYY
Previous eye doctor or clinic:
Are you currently using medication eye drops?
Please list
Self Family Member(s)
Glaucoma
Macular Degeneration
Cataracts
Diabetic Eye Disease
Retinal Detachments
Keratoconus
Amblyopia
Eye Turns
Eye Surgeries
Eye Allergies
Eye Injuries
Eye Infections
Please describe any conditions marked above, and the how the family member is related to you, if applicable:
HEALTH HISTORY
Patient Information:
Height Weight
Primary Care Physician:
Smoking Status:
- Current Smoker
- Former Smoker
- Never Smoked
- Smokeless Tobacco User
Women of childbearing age:
Are you currently pregnant or nursing?
- Yes
- No

	Self	Family Member(s)
Digestive System
Blood / Lymph
Ear / Nose / Throat
Allergies / Immune system
Skin
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.)

Please describe any conditions marked above, and the how the family member is related to you, if applicable:
Please list all medications:
Please list all medication allergies:
Thank you and welcome to our practice!

Patient Welcome Form

Health Insurance Portability and Accountability Act-HIPAA

Payment Information

Authorization for Release of Information

VISION HISTORY

HEALTH HISTORY

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Eyecare Associates

	Self	Family Member(s)
Glaucoma
Macular Degeneration
Cataracts
Diabetic Eye Disease
Retinal Detachments
Keratoconus
Amblyopia
Eye Turns
Eye Surgeries
Eye Allergies
Eye Injuries
Eye Infections