Microsoft Word PatientRegistrationForm 1st 2 Pgs Updated 5 25 16.docx

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1 Patient Registration Please review, make necessary changes and supply any missing information. Patient Name Mr. Mrs. Miss Ms. Salutation Date of Birth Sex SS # Address Zip code City, State Patient Communication Pref. Contact Method Cell Home Work Email Text US Mail Work Phone # Home Phone # Extension Cell Phone # Email Information Primary Care Provider Marital Status Employer Occupation Account Responsible Date of Birth Responsible Relationship SS # Address Home Phone # Work Phone # Extension Email Primary Insurance Group Name Carrier Name ID # Group # Address Phone Insured Date of Birth Secondary Insurance Carrier Name Group Name ID # Group # Address Phone Date of Birth Insured Emergency Contact First Middle Last Relation ship Home# Cell# Work# Release Of Medical Information - Status Name Relationship Release Status

2 I authorize and request examination by the physicians and staff of Harman Eye Centers including optometrists and ophthalmic technicians. I authorize the performance of whatever procedures the judgment of the above -named staff may deem necessary during treatment. I also authorize the administration of any anesthetics and analgesics, including eye drops, which the above staff deem advisable. I may request that any procedure not be performed. I authorize payment directly to Harman Eye Center of the insurance benefits otherwise payabl e to me for their services. I also authorize them to provide information to my insurance company directly pertaining to relevant claims. I understand that I may be charged and I agree to pay a fee for forms completion, medical records, collection agency or attorneys' fees pertaining to my account. By my signature below, I acknowledge that I have received the Harman Eye Center Notice of Privacy Practices. Patient Signature: ___________________________ DATE: __________________ Witness Signature: ___________________________ DATE: __________________ Parent/Legal Representative: __________________ DATE: __________________

3 Insurance Fact Sheet for Non ts - Medicare Patien Name: (please print) Address: Telephone # : (home) (work) (cell) 1. Please circle any issues you are currently having: y Eyes Itch Red E yes Eye Pain Watery Eyes Dry Eyes Glasses don't fi t or work as well Difficulty reading small print Difficulty driving at night Can’t see fine lines Double Vision Problems with glare Floaters Tired of wearing glasses Eye Strain Change in Vision Headaches ids Droopy Eyelids Swollen Eyel “Crow’s Feet” “Laugh Lines” 2. Do you currently wear c ontact lenses? NO YES Are you having problems wearing? YES NO 3 . Have you ever been diagnosed with any of the following? (Please circle all that apply) Glaucoma Cataracts Diabetes Family history of Glaucoma High Blood Pressure JUVEDERM LASIK BOTOX LATISSE 4 . Are you interested in any of the following? ns at Harman Eye Center: Below is an explanation of what routine and medical eye exams include and payment optio A ROUTINE eye exam is to review the health of the eyes and your glasses or contact lens prescription if applicable. Only tting fees are in companies with very specific eye care plans pay for routine examinations. Refraction fees and contact lens fi addition to the exam itself. Please be aware that you are responsible for advising us of your routine vision coverage prior t o your If you want this visit You may be able to use your routine benefits in our optical department. filed as routine, you must eye exam. meet with a staff member to be sure that we participate with your insurance plan. If you have a R OUTINE DIAGNOSIS (no issues other than an updated prescription) have a routine vision plan, we do ask that you pay for th ese services at the time and do not on of of each visit. We accept cash, check, Visa, Discover and MasterCard. We will be happy to give you a receipt and a descripti services rendered to enable you to file your insurance. A MEDICAL exam is to assess any problems that you may be experiencing that may affect your vision (such as a change in your vision) or the comfort of your eyes (such as dry eyes or eye pain). If you are a patient who is being seen regularly in this office for a medical problem (e.g. glaucoma, ca taracts, diabetes, etc.) or if you require specialized testing, your exam will be filed with your medical insurance. If your insurance requires a referral from your primary care provider you are responsible for obtain ing the referral before you are seen. Are you here today for a medical or a routine visit? (Please circle one) MEDICAL ROUTINE If routine, what type of insurance do you have? - payment at each visit. This is a req uirement of our If we participate with your insurance we must collect your co - payment was designed by your insurance company to assist in agreement with your insurance company. Your co - covering the cost of providing care to you. If you do not pay your co pay, you are violating your insurance contract. e our participation agreement by not collecting your co - pay and are not allowed to participate with your If we violat insurance company, the cost of services to you will rise. If you have questions regarding your payment obligations or your particular insurance, train ed staff members are available to help you with your insurance questions. It is important that you keep us up to date with changes in your insurance. If you are an established patient, you are responsible for letting us know if your insurance has changed s ince your last visit and providing us with your current insurance card so that we may make a copy for your recor THANK YOU! ds. Patient Signature Date

4 Harman Eye Center and its affiliates and/or subsidiaries ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES nter Privacy Practices. By signing below, I acknowledge that I have received a copy of Harman eye Ce _____________________________________________ (Print Name) _____________________________________________ (Signature) _____________________________________________ (Date) This acknowledgement page should be retained in the patie nt’s record. If acknowledgement could not be obtained from patient, the reason(s) must be documented below. _______________________________________________________________________________________ ______________________________ _________________________________________________________ ___________________________________________ ________________________________ ___________________________________________________________________________ RELEASE OF MEDICAL INFORMATION By signing below, I authorize Harma n Eye Center and affiliates and/or subsidiaries to disclose information regarding my eye care and treatment to the individuals listed below: _______________________________________________________________________________________ Name Phone Number Relationship _______________________________________________________________________________________ Name Phone Number Relationship _______________________________________________________________________________________ Name Phone Number Relationship ________________________ ______________________ (Signature) ______________________________________________ (Date)

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