Healthcare Eye Doctor Form

HEALTHCARE EYE DOCTOR FORM

Patient Information

Date of Birth:    Gender:    Pronouns:

Phone:    Alternate Phone:    Email:

Relationship:    Phone:

Insurance and Billing Information

Policy/ID Number:    Group Number:

Subscriber DOB:    Subscriber SSN (last 4):

Medical & Ocular History

Do you use corrective lenses?   Glasses   Contacts   None

Consent for Examination and Treatment

I authorize the ophthalmic and clinical staff to perform diagnostic testing and a comprehensive eye examination, including dilation, intraocular pressure measurement, retinal imaging, visual field testing, and other tests as determined necessary by the examining clinician. I understand the purpose, expected benefits, and reasonable risks of these tests and treatments. Risks may include temporary blurred vision, light sensitivity, allergic reaction to drops, dizziness, or, rarely, more serious adverse events. I acknowledge that no guarantee or assurance has been made as to the results of any examination or treatment.

I consent to the use of diagnostic pharmaceutical agents (for example, dilation drops and topical anesthetic) when clinically indicated. I understand I may refuse any specific diagnostic procedure and that refusal will not affect my right to future care.

I understand I may withdraw or limit this consent at any time prior to treatment, except where the withdrawal would frustrate the provision of care already in progress. Questions regarding the examination, tests, and any proposed treatment have been answered to my satisfaction.

If patient is under 18, the signature must be that of a parent or legal guardian. Relationship to patient (if signed by guardian):

Authorization to Release Information & Billing

I authorize release of medical information necessary to process insurance claims and to coordinate my care with other health care providers. I authorize payment of benefits to the treating practice for services rendered. I accept financial responsibility for charges not covered by insurance, including co-payments, deductibles, and non-covered services. This assignment of benefits remains in effect until revoked in writing.

Permission to leave messages regarding appointments, test results, or billing at the phone numbers listed above: Yes   No

HIPAA Privacy Acknowledgment & Authorization

I acknowledge that I have been provided with the practice's Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights under applicable privacy laws. By signing below I authorize the release of my protected health information to insurers, referring providers, and as required for treatment, payment, or health care operations.

Additional persons authorized to receive my protected health information (name and relationship):    Expiration of authorization:

Acknowledgment of Financial Responsibility

I agree that all co-payments are due at the time of service. If I fail to pay balances due, I understand the practice may use collection procedures and I may be responsible for collection costs. I agree that all information I have provided on this form is true and complete to the best of my knowledge.

Patient Certification

By signing below I certify that I have read and understand the statements above, that I am the patient or the patient's authorized representative, and I accept the terms stated in this form.

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