New Patient Health History Form

New Patient Health History Form

New Patient Health History Form

New Patient Health History Form

New Patient Health History Form

New Patient Health History Form

New Patient Health History Form

New Patient Health History Form

Thank you for choosing our practice to take care of your eye care needs! We know that you have a choice in selecting your eye care provider and we strive to provide you with the best service possible. Here are a few of our office policies.

Registration - All patients must complete a patient information form before seeing the Optometrist.

Charges - Full payment is due at the time when services are rendered unless other payment arrangements have been made.

NSF/Closed Accounts - There will be a $35.00 charge added for returned checks or bank returns.

Appointments/No Show - We request 24-hour notice for appointment cancellations. Patients with three (3) missed appointments and/or no shows annually will result in having to take a chance with being a walk-in. Which may cause you to have to wait a long period of time to see the doctor or not being able to be seen that day. If you no show to your appointment you will be charged $25.00. These charges are not payable by your insurance company. You will be required to pay this charge before your next scheduled visit.

Insurance - Insurance cards must be available prior to each visit. Please notify our office if there is a change in your insurance plans or coverage. We file claims as a courtesy to our patients and are only responsible for filing claims to contracted insurance company and the member. Any dispute for unpaid charges from the insurance company will be billed to the member. All patients must have an insurance ID card in order to utilize benefits.

Medication Refills - Refill request needs to be approved by the doctor. If you need a refill this may require you to have to schedule an appointment to see the doctor before a refill can be approved.

Referrals - Allow 5 working days to process routine referrals.

Behavior - Physical and verbal abuse towards the office staff will not be tolerated. This includes disruptions affecting daily operations within the office as well as offensive behavior on the telephone with office personnel. Abusive behavior towards personnel will result in immediate discharge from the practice.

Feedback - You may receive a patient satisfaction survey from Demand Force/Solution Reach. Please take time to complete this and let us know how we are doing.

Thank you for understanding and agreeing to our Office Policies. We are committed to be an involved member of your Eye Care Team working together for your vision!

Parent's or Guardian's Signature
Date

Welcome to Premier Eye Care

Name
DOB
Gender
Age
SS #
Occupation
Address
City
State
Zip
Phone #
Work #
Cellphone #
Email
Emergency Contact
Phone #
Primary Care Doctor Name
Primary Care Doctor Phone #
Last Eye Exam
Receive Promotions and Emails

Insurance Information

Vision Insurance Name
Primary Member Name
Primary Member Date of Birth
Primary Member ID# or SS#
Medical Insurance Name
Primary Member Name
Primary Member Date of Birth
Primary Member ID# or SS#

Family Health History

Please check any conditions that apply to your immediate family members and list family member:

Patient's Ocular/Medical History

Do you have any allergies to medications?
If yes, please list:
List all the medications you are currently taking:
List all the major injuries, surgeries, and/or hospitalization you have had:
Are you pregnant and/or nursing?
Do you wear glasses?
Do you wear contact lenses?
Please check any conditions that you have or have had in the past:

Social History

Do you use tobacco products?
(If yes)type/amount/how long:
Do you drink alcohol?
(If yes)type/amount/how long:
Do you use recreational drugs?
(If yes)type/amount/how long:
Have you ever been exposed to or infected with:
HOW DID YOU HEAR ABOUT US?

Notice of Privacy

Acknowledgement of Receipt of Privacy Notice

The Health Insurance Portability and Accountability Act (HIPPA) is a federal law designated to protect the privacy of your health information. We understand that the information about you and your health is personal, and at Premier Eye Care​​​​​​​, we are committed to protecting the privacy of that information. Because of this commitment, we must obtain your special authorization before we may use or disclose your protected health information to any party. This office will only use and disclose necessary personal health information to permit the office to perform its administrative duties, provide eye care services, process vision benefit claims or mail exam recalls.

By signing below, I acknowledge that I have read/receive copy of the Notice of Privacy Practices for review.

Parent's Signature or Legal Representative
Date

Premier Eye Care

Patient Preference Regarding Communication of Information

In order to better protect your privacy under HIPAA, we have created this consent form releasing medical information to family members and other people of choosing. This will also be used for consent to leave you detailed telephone messages at the mentioned phone numbers, mail you information to your home and also send secure emails to your personal email address.

Many time we have patient's family members call requesting medical information and legally we are not allowed to release that information without the patient's written consent.

Communication to Family Members, Spouses or Other:

Name
DOB

I hereby give my permission for the release of medical information regarding appointments and questions about my condition and treatments to the following person:

Name
Relation
Phone
Name
Relation
Phone
Name
Relation
Phone

Electronic Communication Methods - Premier Eye Care​​​​​​​ uses different methods to communicate with our patients. We communicate appointment reminders, medical records, promotions/events and newsletters. Below check which method you prefer and what service you would like to receive. You can choose one method or all.

Communication via Phone - Detailed messages regarding my health information, appointments, etc may be left on voicemail at the following numbers:

Work
Cell
Home

​​​​​​​Communication via Mailing Address

Appointment Reminders
Promotions/Events
Mailing Address
City
State
Zip

Communication via Text

Appointment Reminders
Promotions/Events
Phone number to receive text

Communication via Email - In choosing your email address, please consider privacy implications; for example, any other person that may have access to your email or any other person, such as your employer, that may have the right and/or ability to review all email received at your work address. Please enter in the space below the email you would like to use.

Appointment Reminders
Promotions/Events
Email Address

Consent and Agreement - I have carefully reviewed this document and agree to fully comply with the guidelines defined herein for the communication of my health information and other office information.

Signature
Date

Patient Financial Responsibility Statement

Thank you for choosing Premier Eye Care for your vision care needs. The purpose of this form is to explain your financial rights and responsibilities as a patient of our practice. By seeking care with Dr. Kim, you are accepting the responsibility of ensuring that payment is made in full for services received. We do our best to verify your insurance benefits and provide you with an estimated amount of what you will owe prior to providing services. However, this is only a quote of benefits and is not always the final amount owed once insurance has been filed.

As a patient, it is in your best interest to know and understand your insurance plan benefits, and your responsibility for any deductibles, co-insurance, or co-pay amounts prior to any visit. Not all services are covered under all insurance contracts. We participate in-network with many insurance companies, and we bill them as a service to you. However, as the patient, you are responsible for payment if your insurance company declines to pay for any reason. By signing below, you agree to:

  • Inform Premier Eye Care​​​​​​​ of the name, date of birth, and full social security number of any insured/financially responsible party prior to your visit.

  • Provide a copy of your current insurance card at each visit.

  • Pay any required co-pay, and, if known, any co-insurance/deductible at each visit.

  • Pay any additional amount not covered by insurance within 30 days of receiving a statement from our office.

  • Pay your visit in full if insurance information is not provided prior to the day of your visit.


It is your right to not provide the information requested. However, it is necessary for our office to have in order to submit insurance claims for you. Should you choose to pay out of pocket for your visits and submit to insurance for reimbursement, we will be happy to provide you with a detailed statement.

** By signing below, I understand that I am financially responsible for my health insurance deductible, co-insurance, co-pay, or any non-covered service. I understand that my insurance plan benefits are a contract between myself and the insurance company, not between the doctor and the insurance company. In addition, a quote of benefits does not guarantee payment, and my doctor is not liable for services that the insurance company deems non-payable. In the event that my insurance company denies payment for a service, I understand that I will be fully responsible for the complete charge and agree to pay the costs of all services provided.

I hereby assign all vision and/or medical benefits, to which I am entitled including Medicare, private insurance, and other health plans to Premier Eye Care​​​​​​​. This assignment will remain effect until revoked by me in writing.

I authorized Premier Eye Care​​​​​​​ to furnish requested information from the patient's medical record and other records to: (1) any insurance company or third party payor for the purpose of obtaining payment on the account (2) any other person(s) or entities responsible for the patient's care or treatment, and (3) representatives of local, state, or federal agencies in accordance with law. Such information may include, but is not limited to, information concerning communicable diseases such as Acquired Immune Deficiency Syndrome ("AIDS"). I authorize the release of information from or for the review of patient's records for purposes of conducting medical audits, utilization reviews, or quality assurance reviews.

Signature (and relationship if not patient)
Date
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