Sharp Sight Eyecare and Dry Eye Center

1Personal Information

First Name *

Last Name *

Date of Birth * (MM/DD/YYYY)

SSN #

2Address *

Street Address *

Address Line 2

City *

State / Province *

ZIP / Postal Code *

3Contact Information

Home Phone

Cell Phone *

Email Address *

By checking this box, you agree to receive SMS messages from Sharp Sight Eyecare related to customer care. You may reply STOP to opt-out at any time. Message frequency will vary.

4Employment

Employer

Occupation

How did you hear about us?

5Insurance Information

6Medical History

Last Primary Care Visit

Primary Care Doctor

Last Eye Exam

Previous Eye Doctor

List Any Previous Surgeries with Dates

Are You Pregnant or Breastfeeding?

YesNo

Hobbies & Sports You Enjoy

How many hours per day do you use the computer?

7Vision-Related Questions

8Medical Conditions & Medications

List any medical and eye conditions you may have

List medications you are taking

List any family medical and eye conditions

List any allergies that you have

9Social History

10Dry Eye Evaluation

11Myopia Control / Management

12Mental Health

Do you suffer from or have endured from the following:

13HIPAA & Communication Preferences

14Location & Signature

Location / Branch *

TylerGun Barrel City

Signature *

By typing your name, you are signing this form electronically.

15Agreements & Acknowledgements

Financial Policy

The doctor and staff at Sharp Sight Eyecare are pleased that you have chosen us for your eye care needs. Please review our financial policy:

Payment for professional services is due the day services are provided.
Eyeglasses are customized products and all optical sales are final.
Payments for copays, deductibles, and items not covered by insurance are due at time of visit.
If we do not participate with your insurance, payment is due in full when services are rendered.
Contact lens wearers are subject to a medical evaluation and fitting fee.
For Flexible Spending Accounts, payment in full is due for services rendered.
If insurance payment is not received in 60 days, you will be responsible for the full balance.
Finance charges at 1.5% per month (18% APR) will accrue on outstanding balances.
Parents requesting treatment for children are responsible for all fees incurred.
If legal action is pursued for unpaid charges, you will be billed attorney fees and collection costs.

I have read and understand the above information and agree to the terms set forth in this agreement. *

Contact Lens Prescription Acknowledgement

I acknowledge that I was provided with a copy of my contact lens prescription at the completion of my contact lens fitting and understand the CDC and FDA recommendations for safe contact lens use.

I acknowledge the contact lens prescription acknowledgement. (Optional)

Permission for Telehealth Visits

What is telehealth?

Telehealth is a way to visit with healthcare providers, such as your doctor or nurse practitioner.

How do I use telehealth?

You talk to your provider by phone, computer, or tablet.
Sometimes, you use video so you and your provider can see each other.

Can telehealth be bad for me?

You and your provider won't be in the same room, so it may feel different than an office visit.
Your provider may decide you still need an office visit.
Technical problems may interrupt or stop your visit before you are done.

Will my telehealth visit be private?

We will not record visits with your provider.
If people are close to you, they may hear something you did not want them to know. You should be in a private place, so other people cannot hear you.
Your provider will tell you if someone else from their office can hear or see you.
We use telehealth technology that is designed to protect your privacy.

How much does a telehealth visit cost?

What you pay depends on your insurance.
A telehealth visit will not cost any more than an office visit.
If your provider decides you need an office visit in addition to your telehealth visit, you may have to pay for both visits.

What does it mean if I sign this document?

If you sign this document, you agree that:

We talked about the information in this document.
We answered all your questions.
You consent to a telehealth visit.

I consent to telehealth visits *

Your Signature *

Date *

HIPAA Consent Form

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a "friendly" version. A more complete text is posted in the office.

What this is all about:

Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient's condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
We agree to provide patients with access to their records in accordance with state and federal laws.
We may change, add, delete or modify any of these provisions to better serve the needs of both the practice and the patient.
You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

I consent and acknowledge my agreement to the HIPAA Information Form *

Patient Welcome Form