Patient InformationLegal Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Your AgePlease enter a number from 1 to 105.GenderMaleFemaleOtherRaceAfrican AmericanAmerican IndianAsianHispanicWhiteAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work PhoneCell PhoneEmail* Enter Email Confirm Email Preferred Method of ContactWorkCellTextEmailMailOccupationHobbiesEmergency Contact Name* First Last Emergency Contact Relationship*Emergency Contact Phone*Medical InsuranceMedical Insurance ID #Medical Insurance GroupPolicy holder's name First Last Policy holder's date of birth Date Format: MM slash DD slash YYYY Vision InsuranceAetnaAPIPAAsbaitAvesisBlue Cross/Blue ShieldCMDPDavis VisionDirectEyemedHealthnetHumanaPacificare (Eye Specialist)Spectera (Optum)SuperiorTri-CareUnited HealthcareUniversity Family CareVision CareVision Service Plan (VSP)Vision Insurance ID #Primary Care PhysicianPrimary Care Physician First Last Primary Care Physician PhonePrimary Care Physician FAXFamily Medical & Ocular HistoryDid any of the following relatives have issues with:DiabetesNoneFatherMotherGrandparentsAunt or UncleCousinsOtherHigh Blood PressureNoneFatherMotherGrandparentsAunt or UncleCousinsOtherHigh CholestrerolNoneFatherMotherGrandparentsAunt or UncleCousinsOtherCataractsNoneFatherMotherGrandparentsAunt or UncleCousinsOtherGlaucomaNoneFatherMotherGrandparentsAunt or UncleCousinsOtherMacular DegenerationNoneFatherMotherGrandparentsAunt or UncleCousinsOtherBlindnessNoneFatherMotherGrandparentsAunt or UncleCousinsOther Other Medical or Ocular Family History OtherNoneFatherMotherGrandparentsAunt or UncleCousinsOtherPatient Medical & Ocular HistoryPlease list any of your medications that are not related to your eyesPlease list any eye medications you are currently usingPlease list any known allergies to medicationPatient Medical History Ear/Nose/Throat High Blood Pressure Stroke High Cholesterol Endocrine Disorder Diabetes Headaches Asthma Cancer Kidney Disease Psychiatric Disorder Neurological DIsorder Musculoskeletal Disorder Immune Disorder Check any with which you have had medical issues.If you have diabetes, when was your last A1C?Patient Ocular History Light Sensitivity Dry Eyes Floaters in Vision Flashes in Vision Glaucoma Macular Degeneration Strabismus Amblyopia Cataracts Retinal Detachment Injury/Surgery Check any with which you have had medical issues.Have you had cataract surgery? Yes No Which eye(s) had cataract surgery? Left Right Both What was the date(s) of your cataract surgery(ies)?Which eye(s) had retinal detachment? Left Right Both When did retinal detachment occur?Which eye(s) had an injury or surgery? Left Right Both Describe the injury and/or surgery:Reason for your visitDate of your last eye exam Date Format: MM slash DD slash YYYY Do you wear glasses or contacts (check all that apply)?* Glasses Soft Contacts Hard Contacts None Type of glassesBrand of contactsYour contact wear schedulePrescriptionWhy have you come in to visit?*How did you hear about Arizona Primary Eye Care?Google or other Web searchInsuranceFriend or FamilyDo you remember the search term?Social History Check if you smoke tobacco Check if you have done illegal drugs Check if you drink alcohol Other social history health concernsNotice of Privacy PracticesThis notice of privacy practices ("Notice") describes how we may use or disclose your health information and how you can get access to such information. Please read it carefully.* I acknowledge that I received a copy of Arizona Primary Eye Care’s, Notice of Privacy Practices. Your "health information," for purposes of this Notice, is generally any information that identifies you and is created, received, maintained or transmitted by us in the course of providing health care items or services to you (referred to as "health information" in this Notice). We are required by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and other applicable laws to maintain the privacy of your health information, to provide individuals with this Notice of our legal duties and privacy practices with respect to such information, and to abide by the terms of this Notice. We are also required by law to notify affected individuals following a breach of their unsecured health information. Uses and Disclosures of Information Without Your AuthorizationThe most common reasons why we use or disclose your health information are for treatment, payment or health care operations. Examples of how we use or disclose your health information for treatment purposes are: setting up an appointment for you; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and faxing them to be filled; showing you low vision aids; referring you to another doctor or clinic for eye care or low vision aids or services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or vision care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). "Health care operations" mean those administrative and managerial functions that we must carry out in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records. Other Disclosures and Uses We May Make Without Your Authorization or Consent In some limited situations, the law allows or requires us to use or disclose your health information without your consent or authorization. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are: • when a state or federal law mandates that certain health information be reported for a specific purpose; • for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices; • disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence; • uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws; • disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies; • disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else; • disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations; • uses or disclosures for health related research; • uses and disclosures to prevent a serious threat to health or safety; • uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service; • disclosures of de-identified information; • disclosures relating to worker’s compensation programs; • disclosures of a "limited data set" for research, public health, or health care operations; • incidental disclosures that are an unavoidable by-product of permitted uses or disclosures; • disclosures to "business associates" and their subcontractors who perform health care operations for us and who commit to respect the privacy of your health information in accordance with HIPAA; Unless you object, we will also share relevant information about your care with any of your personal representatives who are helping you with your eye care. Upon your death, we may disclose to your family members or to other persons who were involved in your care or payment for heath care prior to your death (such as your personal representative) health information relevant to their involvement in your care unless doing so is inconsistent with your preferences as expressed to us prior to your death. Specific Uses and Disclosures of Information Requiring Your Authorization The following are some specific uses and disclosures we may not make of your health information without your authorization: Marketing Activities. We must obtain your authorization prior to using or disclosing any of your health information for marketing purposes unless such marketing communications take the form of face-to-face communications we may make with individuals or promotional gifts of nominal value that we may provide. If such marketing involves financial payment to us from a third party your authorization must also include consent to such payment. Sale of Health Information. We do not currently sell or plan to sell your health information and we must seek your authorization prior to doing so. Psychotherapy Notes. Although we do not create or maintain psychotherapy notes on our patients, we are required to notify you that we generally must obtain your authorization prior to using or disclosing any such notes. Your Rights to Provide an Authorization for Other Uses and Disclosures • Other uses and disclosures of your health information that are not described in this Notice will be made only with your written authorization. • You may give us written authorization permitting us to use your health information or to disclose it to anyone for any purpose. • We will obtain your written authorization for uses and disclosures of your health information that are not identified in this Notice or are not otherwise permitted by applicable law. • We must agree to your request to restrict disclosure of your health information to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and such information pertains solely to a health care item or service for which you have paid in full (or for which another person other than the health plan has paid in full on your behalf). Any authorization you provide to us regarding the use and disclosure of your health information may be revoked by you in writing at any time. After you revoke your authorization, we will no longer use or disclose your health information for the reasons described in the authorization. However, we are generally unable to retract any disclosures that we may have already made with your authorization. We may also be required to disclose health information as necessary for purposes of payment for services received by you prior to the date you revoked your authorization. Your Individual Rights You have many rights concerning the confidentiality of your health information. You have the right: • To request restrictions on the health information we may use and disclose for treatment, payment and health care operations. We are not required to agree to these requests. To request restrictions, please send a written request to us at the address below. • To receive confidential communications of health information about you in any manner other than described in our authorization request form. You must make such requests in writing to the address below. However, we reserve the right to determine if we will be able to continue your treatment under such restrictive authorizations. • To inspect or copy your health information. You must make such requests in writing to the address below. If you request a copy of your health information we may charge you a fee for the cost of copying, mailing or other supplies. In certain circumstances we may deny your request to inspect or copy your health information, subject to applicable law. • To amend health information. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, you must write to us at the address below. You must also give us a reason to support your request. We may deny your request to amend your health information if it is not in writing or does not provide a reason to support your request. We may also deny your request if the health information: •was not created by us, unless the person that created the information is no longer available to make the amendment, •is not part of the health information kept by or for us, •is not part of the information you would be permitted to inspect or copy, or •is accurate and complete. • To receive an accounting of disclosures of your health information. You must make such requests in writing to the address below. Not all health information is subject to this request. Your request must state a time period for the information you would like to receive, no longer than 6 years prior to the date of your request and may not include dates before April 14, 2003. Your request must state how you would like to receive the report (paper, electronically). • To designate another party to receive your health information. If your request for access of your health information directs us to transmit a copy of the health information directly to another person the request must be made by you in writing to the address below and must clearly identify the designated recipient and where to send the copy of the health information. Contact Person: Our contact person for all questions, requests or for further information related to the privacy of your health information is: Michele Hennen [email protected] Complaints: If you think that we have not properly respected the privacy of your health information, you are free to complain to us or to the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mail shown above. If you prefer, you can discuss your complaint in person or by phone. Changes to This Notice: We reserve the right to change our privacy practices and to apply the revised practices to health information about you that we already have. Any revision to our privacy practices will be described in a revised Notice that will be posted prominently in our facility. Copies of this Notice are also available upon request at our reception area. Notice Revised and Effective: September 23rd, 2013 Patient Release During your vision examination, should a medical condition be identified, please be advised it is not covered under your routine vision exam. Medical Conditions are billed under your medical insurance and your specialist copay will be required. In accordance with the HIPPA laws and regulations, I authorize the release of any information including the diagnosis and treatment rendered to me during my examination to third payers and/or health care practitioners. I authorize and request Arizona Primary Eye Care to bill my insurance carrier/carriers according to my diagnosis as well as my eyewear needs. I authorize and request my insurance carrier to pay directly to this provider's office. I also understand that although an authorization has been provided to my insurance carrier that it is not a guarantee of payment by the insurance carrier. I agree to be responsible for any and all payment for services that is not paid by my insurance.SignatureIf you hit 'Submit' and don't move on to the next screen, scroll up - you've probably missed a required field in the form.EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.