Notice of Privacy Practices Methods of Payments

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1 Notice of Privacy Practices Methods of Payments No Insurance? No problem! Claremore Eye Associates offers a discount for all non- insurance patients for their vision exam. We also accept all major credit cards, as well as Care Credit, cash and checks. Vision Plans Some insurance plans do not provide an insurance card Vision plans (examples: VSP, EyeMEd, Comp8Benefits/Humana, etc.); usually include benefits towards either glasses or contact lenses a very select few plans may cover both or offer a second of glasses per year for patients less than 20 years of age, and they do NOT cover contact lenses. Medical Insurance Refractions (checking vision/glasses prescription) and the contact lens portion of the exam are not generally covered by medical plans. We can file your insurance on your behalf, but this does not guarantee payment and any balance will be paid by you. If your deductible has not yet been met for the year, you will be responsible for services rendered. We keep medical insurance information on file because we perform medical eye care. We use medical insurance for infections, foreign body removals, eye disease, treatments, etc. We are glad to answer any questions regarding your insurance benefits. Thanks! Authorization & Release I authorize the release of any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the doctor insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I authorize the release of any information including the diagnosis and records of any treatment or examinations rendered to me or my child to: I acknowledge that I have read or have had the opportunity to read the Notice of Privacy Practices (available at the front desk). Patient Name: Date: Signature of Patient or Guardian:

2 GENERAL INFORMATION Today s Date: Last Exam: Name: Last First Middle Street: City: State: Zip: Home Phone: Cell Phone: Address: Preferred Method of Communication: Home Cell Text Preferred Language: English Spanish Other Thank you very much for choosing Claremore Eye Associates Vision Source and Drs. Smith, Stover and Crissup for your vision and eye health care! We value your opinion and hope to provide you with the best care. Please let us know if there is any way we can improve your visit. Race (circle): White, American Indian/Alaska Native, Asian, African American, Hispanic, Native Hawaiian/other Pacific Islander Ethnicity (circle): Hispanic/Latino, Native Hawaiian/ other Pacific Islander, Not Hispanic or Latino Social Security Number: Employer (or School): Occupation (or Grade): Date of Birth: Sex: Vision Insurance: Medical Insurance: Insured s Name: Insured s Employer: Insured s SS#: Group #: Welcome to Our Office Do you Work at computer for long periods? Yes/No Want information on thinner or more technologically advanced lenses? Yes/No Have prescription sunglasses? Yes/No Spend a lot of time outdoors? Yes/No Have an interest in laser vision correction? Yes/No Have you ever worn/currently wear soft contact lenses? Yes/No What kind? Cleaning solution for contacts? Are you interested in contact lenses? Yes/No EYE HISTORY Have you had any of the following: Are you currently experiencing any of the following? Yes No Yes No Yes No Yes No Eye Injury o o Itching o o Flashes of light o o Burning o o Eye Surgery o o Nausea o o Headaches o o Sensitivity to light o o Eye disease o o Tearing o o Redness o o Gritty feeling in eye o o Lazy eye o o Dryness o o Double vision o o Objects floating o o Cataracts o o Eyestrain o o Blurry near o o Poor night vision o o Glaucoma o o Soreness o o Blurry distance o o Glare o o Name of primary physician, additional referring physician: Please list any sports or hobbies: Allergies to Medication & reaction:

3 FAMILY MEDICAL HISTORY Relationship SOCIAL HISTORY (please circle) Information will be kept confidential. Blindness No Yes Never Smoked Cataracts No Yes Former Smoker, quit (circle) <1yr, 1-2yrs, 3-4yrs, 4-5yrs, Glaucoma No Yes 5+yrs, 10+yrs ago Diabetes No Yes Current Someday/Everyday smoker, PPD, yrs Heart Disease No Yes Current Smokeless Tobacco user High Blood Pressure No Yes Alcohol use, amount, how often Macular Degeneration No Yes Recreational drug use PATIENT MEDICAL HISTORY QUESTIONAIRE Review of Systems Please indicate if you are currently experiencing problems/symptoms in the following areas. Please list any prescription or over the counter medications you are taking for these problems. Yes No Describe/List Medications Constitutional (fever, weight loss/gain, fatigue) Ear/nose/throat/mouth/dental (ulcers, infections, deafness) Cardiovascular (high blood pressure, high cholesterol, palpitations, chest pain, congestive heart failure, bypass) Respiratory (cough, shortness of breath, asthma) Gastrointestinal (diarrhea, constipation, jaundice) Neurological (vertigo, tingling, numbness, headaches) Musculoskeletal (weakness, joint pain, back pain) Endocrine (diabetic, thyroid) Hematological/Lymphatic (anemia, freq infections, bleeding) Allergic/Immunology (autoimmune, arthritis, immune deficiency) Genitourinary (frequency, urgency, dysfunction) Psychiatric (depression, anxiety, attention disorder) Skin/Breast (rashes, lesions) Ocular (glaucoma, infections, allergies, cataracts, macular degeneration) Reviewed by Date

4 Date: Last exam: Name: Last First Middle Street: City: State: Zip: Home Phone: Cell phone: Address: Emergency Contact Name & Phone #: Thank you very much for choosing Claremore Eye Associates Vision Source and Drs. S. Smith, Stover and Crissup for your vision and eye health care. We value your opinion and hope to provide you with the best care. Please let us know if there is any way we can improve your visit. Race (circle): White, American Indian/Alaska Native, Asian, African American, Hispanic, Native Hawaiian/Other, Pacific Islander Ethnicity (circle): Hispanic/Latino, Native Hawaiian/other, Pacific Islander, Not Hispanic or Latino Social Security Number: Employer (or School): Occupation (or Grade): Date of Birth: Sex: Vision insurance: Medical insurance: Insured s Name: Insured s Employer: Insured s SS#: Group #: Welcome to Our Office Do you Work at a computer for long periods Want information on thinner or more Technologically advanced lenses? Have prescription sunglasses? Spend a lot of time outdoors? Have an interest in laser vision correction? Have you ever worn/currently wear soft contact Lenses? What kind? Cleaning solution for contact? Are you interested in contact lenses? Eye History Have you had any of the following Are you currently experiencing any of the following? Yes no Yes No Yes No Yes No Eye injury Itching Flashes of light Burning Eye Surgery Nausea Headaches Sensitivity to light Eye Disease Tearing Redness Gritty feeling in eye Lazy Eye Dryness Double Vision Objects floating Cataracts Eyestrain Blurry near Poor Night vision Glaucoma Soreness Blurry distant Glare Name of Primary Physician, additional referring physician Please List any sports or hobbies Allergies to Medication & Reaction Family Medical History Relationship Social History (please circle) information will be kept confidential Blindness No Yes Never Smoked Former Smoker- Quit (circle) <1yr- 2yrs, 3-4yrs, 4-5 yrs Cataracts No Yes 5+yrs, 10 + yrs ago Glaucoma No Yes Current Someday/Every day smoker PPD yrs Diabetes No Yes Current Smokeless Tobacco user Heart Disease No Yes Alcohol use, amount how often High Blood Pressure No Yes Recreational drug use Macular Degeneration No Yes

5 PATIENT MEDICAL HISTORY QUESTIONAIRE Review of Systems Please indicate if you are currently experiencing problems in the following areas. Please list any prescription or over the counter medications you are taking for these problems. Yes No Describe/List Medications Constitutional (Fever, weight loss/gain, fatigue) Ear/nose/throat/mouth/dental (Ulcers, infections, deafness) Cardiovascular (High blood pressure, high cholesterol, palpitations, chest pain, congestive heart failure, bypasses) Respiratory (Cough, shortness of breath, asthma) Gastrointestinal (Diarrhea, constipation, jaundice) Neurological (Vertigo, tingling, numbness, headaches) Musculoskeletal (Weakness, joint pain, back pain) Endocrine (Diabetic, thyroid) Hematological/Lymphatic (Anemia, freq infections, bleeding) Allergic/immunology (Autoimmune, arthritis, immune deficiency) Genitourinary (Frequency, urgency, dysfunction) Psychiatric (Depression, anxiety, attention disorder) Skin/Breast (Rashes, lesions) Ocular (Glaucoma, infections, allergies, cataracts, macular degeneration) Reviewed by date Update reviewed by date

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