Welcome to our office HiddenDate MM slash DD slash YYYY Name* First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cell Phone*Work PhoneHome PhoneWhere do you work? SSNDate of Birth MM slash DD slash YYYY Sex Email Address* How do you prefer us to contact you? Text Cell Home Email Emergency Contact PhoneMarital Status Spouse's Name Race (optional) Primary Language (optional) Special Needs (optional) Preferred Pharmacy Responsible Party Date of Birth MM slash DD slash YYYY Relationship to Patient PhoneResponsible Party's Workplace PhoneInsurance InformationVision Plan Member or Subscriber SSNDate of Birth MM slash DD slash YYYY Primary Medical Insurance Member or Subscriber SSNDate of Birth MM slash DD slash YYYY Secondary Medical Insurance SSNDate of Birth MM slash DD slash YYYY How will you be paying for your services today? Cash Check Credit/Debit Do you participate in a Health Savings Account or Flex Spending Account? Yes No When was your last exam? Where was your last exam? Should you need refractive correction, are you wanting glasses, contacts or both? If you are an experienced contact lens wearer, what brand do you wear? What solution do you use? What problems have you been having? Please check all that apply. Blurry Vision Eye Irritation Sunlight Sensitivity Eye Turn/Crossed Eye Flashes of Light Double Vision Dryness Floaters or Spots Headaches Trouble Seeing at Night Other Please Explain We also offer our I Wellness Screening that reveals early indications of retinal or nerve disease. This screening is a non-invasive “picture” of the interior portion of your eye referred to as your retina. Dr. Vaughan recommends that every patient consider this screening as it helps to detect any vision threatening issues or any systemic disease. As a new patient, Dr. Vaughan will also use this screening as a baseline of retinal health. These images will help her determine what is normal for you as an individual. From these images, Dr. Vaughan will be able to detect any small changes that may happen over time. This information can be valuable in seeing changes over time. If you want to have this important screening performed today, please check the box below and we will see to it that our technician discusses it with you. We are offering this important test for only $39 as it is truly a helpful tool. It is, however, not covered by most insurances. Should you decide to have this test performed, the charge will be your responsibility. Yes, I want to have the I Wellness ScreeningMedical HistoryPlease tell us about the history of eye disease in your familyPlease tell us about the family history of any other diseases in your familyName of your Physician Where is your Physician Located Date of Last Physical Exam Current Medications (including vitamins, eye drops or birth control)Do you have any allergies to any medications? Yes what medications? Please list any diseases, disorders, surgeries or physical problems that are an issue for you now or in the pastDo you smoke? Yes Have you ever smoked? Yes Do you use other tobacco products? Yes Do you vape? Yes Do you use alcohol? Yes Have you ever been exposed to or infected with Gonorrhea, Hepatitis, HIV or Syphilis? Yes which one(s) Whom may we thank for referring you to our office today? If there was not a referral, how did you hear about us? We are required by law to have your signature on file stating that you received a copy of the Privacy Notice. (We will provide a copy at your request.) I acknowledge that I have been offered a copy of the Privacy Notice for the office of My Family Eyecare. I also give my permission for the office to correspond with me via email.Dilation is a significant part of the eye health examination. It should be performed at least every two years. I give my permission to have Dr. Vaughan dilate my eyes today. Yes No I certify that the information given by me in applying for payment by my insurance company is correct. I authorize use of this form on all my claim submissions I authorize release of information to all of my insurances companies as needed to process claims for payment. I authorize my doctor to act as my agent in helping obtain payment from my insurance companies. I authorize payment directly to my doctor. I permit a copy of this authorization to be used in place of the original. I authorize the release of personal health information to any other physicians or personnel who who may be utilized. IMPORTANT: Payment is expected today for all copays, deductibles and non-covered services. As a courtesy to you we will bill your insurance for you for those services they may cover. We will make a good faith effort to collect all payments from your insurance companies for the services we provide to you. However, if payment is not received from your insurance companies within 60 days of filing, the balance will become your responsibility. I have read all of the above and I give my consent and permission for each as it is written.Signature*Patient Financial Responsibility StatementMedical Insurance vs. Routine Vision PlansPatients often have both medical and insurance and vision plans. Because they are very different in terms of the services and/or materials that they cover, it is very important to us that you understand the differences. Vision care plans (Eyemed, Superior, VSP, etc.) ONLY cover routine services. This means that if you have a “refractive error” without a medical condition and you simply need glasses or contact to correct your vision, they may help you pay for your routine vision exam and the necessary materials. Most vision plans WILL NOT cover charges for medical issues we may encounter. If the examination today is to follow or treat a medical condition (macular degeneration, diabetes, glaucoma, dry eye, cataracts, etc.) your service today will be billed to your medical insurance coverage upon check in. To our patients without insurance: Payment for all services rendered is due at the conclusion of the visit. If you are ordering materials, our policy requires half of the amount due at the time we order your materials. The remaining half is due upon the dispensing of your glasses/contacts. To our patients with insurance: (Medical or Vision): It is our pleasure to help you file your insurance claim forms or take assignment with your insurance benefits as designated by the plan of which you have indicated you are a member A “refraction” fee of $39 is NOT COVERED by most medical insurance. If your visit results in a medical diagnosis and we bill your medical insurance, the $39 refraction fee will be your responsibility at checkout. You will also be responsible for all medical co-pays, deductibles or any non-covered service. If you have no medical diagnosis and we file your vision insurance, you are responsible for all co-pays and/or non-covered materials or fees. If any materials are ordered, our policy requires half of the amount due at the time we order the materials. The remaining half is due upon the dispensing of your glasses/contacts. All insurances for which the patient is a member must be stated and presented at the time of the visit and WILL NOT be accepted after services are rendered. If you have vision insurance and medical insurance, we will work to minimize your out of pocket expense by coordinating benefits between the two plans if allowed. To our patients who wear contacts: We charge a higher fee for our contact lens exams as they require more information gathering and interpretation. Contact lens wearers will also pay an additional contact lens evaluation and training fee to cover the training involved for the daily use and maintenance of the lenses. This fee also covers the doctor's time to determine the lenses that will provide optimal vision and eye health. Experienced wearers may pay a lesser evaluation fee as training will not be necessary. In addition, fees will be determined by the type of lens required for both first time wearers and those experience with contact lenses. Some vision plans and most medical plans will not pay for this additional evaluation. Thus, it will be your responsibility at check out. Once lenses are determined the day of the appointment and you have received the necessary training, we will have you return for a follow up appointment to make sure the lenses are working well and are healthy. If changes are required, our policy dictates that we will allow 2 more appointments (at not charge) within 60 day period to fine tune or correct any issues. Financial Responsibility: In the event that your medical or vision plan denies payment for services or materials, you hereby agree to be financially responsible for any and all charges incurred by you or your child/dependent. In the event that any payments are not made, all finance fees, collection fees and attorney fees will be your responsibility as well. Responsibility Statement for (name of patient) Patient/Guardian name Patient/Guardian SIGNATURE*
