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Today’s Date:
PATIENT INFORMATION
Patient’s Last Name: First: Middle: Nickname:
Social Security: Salutation: Sex:
Birth Date: Primary Language: Race: Ethnicity:
Address: [Address/ P.O Box, City, ST ZIP Code]
Home Phone No.: Cell Phone No.: Work Phone No.: (include extension)
Email: Marital Status:
Other family members seen here: [Other patients] RESPONSIBLE PARTY
Last Name: First: Middle: Birth Date: Sex:
Address: [Address/ P.O Box, City, ST ZIP Code]
Home Phone No.: Cell Phone No.: Work Phone No.: (include extension)
Email: Social Security:
Demographic Information Form
How did you hear about us?
Were you referred by your doctor? If so, please list the doctor's name
Emergency Contact
Name: Phone: Relationship:
Turn over --->
Primary Insurance Information
Today’s Date:
INSURED INFORMATION
Insured is: Carrier Insurance Name:
Last name: First Name: Middle Initial:
Birth Date: Relationship to Insured
Policy Number: Group Number:
Secondary Insurance Information (If applicable)
INSURED INFORMATION
Insured is: Carrier Insurance Name:
Last name: First Name: Middle Initial:
Birth Date: Relationship to Insured
Policy Number: Group Number:
Insurance Information Form
Responsible Party Signature Today's Date
The above information is true to the best of my knowledge. I authorize my insurance benefits to paid directly to Peak Vision Center. I understand that I am financially responsible for any balance. I also authorize Peak Vision Center or insurance company to release any information required to pay my claims.
Disclosure: Our patients have the right to know the financial interest or ownership in hospitals and/or facilities. Dr. Chang and Dr. Burden have ownership in Premier Surgery Center.
• I have received and signed the Financial Policy of Peak Vision Center• I have received and signed a copy of the Notice of Medical Information Privacy Rights for Peak Vision Center• If you have an account that is turned over to collections you will be responsible for your balance, attorney
fees, and collection fees.• I may be responsible for a refraction fee of 40.00 and I understand Medicare will not pay that fee.• I may be responsible for facility, anesthesia, and laboratory fees.• I understand there is a no show fee of 30.00
Health History FormPlease Fill Out Entire Form
Name: Date of Birth:
Primary Physician: Phone:Referring Provider:
Review of Symptoms: Check all that apply
Eyes:Blurry VisionBurning/DrynessDouble VisionExcess Tearing/Watering
Glare/Light Sensitivity
Itching/ScratchingLoss of VisionLoss of Side VisionPain or SorenessRedness Reading In General
Seeing at a Distance
Additional Concerns:
Eye History:CataractGlaucomaEye MuscleOther
Date Diagnosed Date SurgeryRetina ProblemEyelidRefractive
Date Diagnosed Date Surgery
Current Eye Medications:
Current Medications and Usage:
Over the Counter Medication:
Allergies to Medicines:
Height: Weight:
Surgical History (with dates):
Family History (Check those that Apply and Write the Relationship to you)Cataract Macular DegenerationGlaucomaBlindness Cancer DiabetesCardiovascular Disease StrokeOther Major Illness or Hereditary Disorder
Turn over --->
Constitutional SystemsFeverWeight Loss/Weight GainTrouble Sleeping/Insomnia
Medical History: Check all that apply
Cardiovascular
High Blood Pressure
Congestive Heart FailureHeart Attack/Coronary StentArrhythmia (AFib, tachy, etc)
Elevated CholesterolHistory of Bypass SurgeryPacemaker/ICD
Hearing Problems/TinnitusEars, Nose, Mouth, Throat
Respiratory
Sinus Congestion
EmphysemaAsthmaLung CancerSleep ApneaCOPDChronic Cough/BronchitisOxygen Use
Neurological
Multiple Sclerosis
Migraines/HeadachesSeizures/EpilepsyStroke
Parkinson’s DiseaseAlzheimer’s/DementiaVertigo
G.E.R.D/Acid Reflux
GastrointestinalHepatitisUlcers/BleedingStomach/Bowel Cancer
Overactive Bladder
GenitourinaryEnlarged Prostate/Prostate CancerCervical/Ovarian/Uterine CancerKidney Disease
Currently Pregnant
Bell’s Palsy
MusculoskeletalOsteopenia/OsteoporosisDegenerative (Osteo) ArthritisGout
Fibromyalgia
IntegumentaryShinglesSkin CancerEczema/Psoriasis
Lymphoma
Hematologic/LymphaticAnemia/Sickle CellHemophiliaLeukemia
Lyme Disease
Schizophrenia
PsychiatricDepression/BipolarAnxietyPTSD
Mentally Disabled
Hyperthyroidism
EndocrineType 1 Diabetes Type 2 DiabetesHypothyroidism
Breast Cancer
Lupus
Allergic/ImmunologicSeasonal Allergies/Hay FeverRheumatoid ArthritisSjogren’s (dry eye/mouth)
HIVOther Immune Disorder
Social HistoryAlcohol Everyday Occasional
None
Tobacco Heavy Light ChewNever
Drugs Marijuana OtherNone
Exercise Yes No
Latest Hgb/A1c
Explanation of Other Diagnosed Medical Condition Not Listed:
Date: Signature:
Former
SUMMARY NOTICE OF PRIVACY PRACTICES
THIS IS A SUMMARY OF OUR NOTICE OF PRIVACY PRACTICES, WHICH DESCRIBES HOW
MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION.
Our Notice of Privacy Practices provides information about how we may use and disclose protected health
information about you. The notice contains Patient rights section describing your rights under the law. You
have the right to review our Notice before signing this Consent. You may obtain a copy by asking the front
desk or Privacy Officer. The terms of our Notice may change. If we change our Notice, you may obtain a
revised copy.
Our pledge to protect your privacy:
Skyline Vision Clinic and Laser Center is committed to protecting the privacy of your medical
information. Your care and treatment is recorded in a medical record. So that we can best meet your medical needs, we share your medical record with the providers involved in your care. We share your
information only to the extent necessary to collect payment for the services we provide, to conduct our business operations, and to comply with the laws that govern health care. We will not use or disclose
your information for any other purpose without your permission.
Patient Rights - You have the following rights regarding your medical information: ▪ to request to inspect and obtain a copy of your medical records, subject to certain limited
exceptions; ▪ to request to add an addendum to or correct your medical record; ▪ to request an accounting of Skyline Vision Clinic and Laser Center disclosures of your medical
information; ▪ to request restrictions on certain uses or disclosures of your medical information; to request that
we communicate with you in a certain way or at a certain location; and to receive a copy of the
full version of our Notice of Privacy Practices.
We may use and disclose medical information about you for the following purposes:
▪ to provide you with medical treatment and services; ▪ to bill and receive payment for the treatment and services you receive; ▪ for functions necessary to run Skyline Vision Clinic and Laser Center and assure that our
Patients receive quality care; ▪ to provide basic contact information (no medical information is provided) to our development
office for purposes of fundraising for Skyline Vision Clinic and Laser Center; to support our
standing as a federally qualified health center; and as required or permitted by law.
ACKNOWLEDGEMENT OF RECEIPT
OF SUMMARY NOTICE OF PRIVACY PRACTICES
Revised May 17, 2018
By signing this form, you consent to our use and disclosure of protected health information about you for treatment,
payment and health care operations. You have the right to revoke the Consent in writing, signed by you. However,
such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. Skyline
Vision Clinic and Laser Center provides this form to comply with the Health Insurance Portability and
Accountability Act of 1996 (HIPAA).
_____________________________ ________________________________ __________
Name of Patient (print) Signature of Patient Date
_____________________________ ________________________________ __________ Signature of Patient Representative Relationship to Patient Date
(Required if Patient is a minor or an adult who is unable to sign this form)
I understand that my health care and the payment for my health care will not be affected if I do not sign this form
________ initials
Communication Preferences:
Home phone number: ___________________ Mobile phone number: __________________
In caring for our patients, it may be necessary for Skyline Vision Clinic and Laser Center staff to contact you by
phone. When we are not able to speak to you directly, we like to leave messages when possible. In order to protect
your privacy, it is Skyline Vision Clinic and Laser Center’s policy to not leave messages with anyone except the
patient or legal guardian, nor leave specific information on an answering machine/voicemail system unless we have
your written permission to do so.
Yes, I want you to leave a voice mail. (Please circle) Home Mobile
No, I do not want you to leave a voice mail.
Skyline Vision Clinic and Laser Center may disclose your medical information such as exams, labs/radiology
results, appointments and your insurance or billing information to the following people:
____________________________________________ ________________________________________
Name Relationship Phone Number Name Relationship Phone Number
____________________________________________ ________________________________________
Name Relationship Phone Number Name Relationship Phone Number
No, I do not want you to discuss my medical care with anyone other than me.
I request removal from lists that initiate promotional or marketing communications Yes: _______ initials