Accurate Family Vision Welcome to our office!

Last Name: First Name: Date of Birth:

Address Line 1: Address Line 2:

City, State & Zip: Email Address:

Home Phone: Daytime Phone: Cell Phone:

Employer/Occupation: Hobbies: Hours Per Day on a Computer:

How did you hear about our office?

_____________________________________________________________________________________

Vision Insurance

Primary Insured Name: Primary Insured Date of Birth:

Relationship to Insured:

Insurance Provider:

Employers Name:

Insured Identification Number: Insured Group Number:

Medical Insurance

Primary Insured Name:

Primary Insured Date of Birth:

Relationship to Insured:

Insurance Provider:

Employers Name:

Insured Identification Number: Insured Group Number:

______________________________________________________________________________________________

Acknowledgement of Receipt of Notice of Privacy Practices

I, _______________________________________________________, have received a copy of this office’s Notice of Privacy Practices Policy.

(PRINT PATIENT NAME)

Accurate Family Vision will maintain the privacy of your health information and personal data.

_____________________________________________________________________________________ Date_____________________

Signature of Patient or Parent/Legal Guardian

Statement of Financial Responsibility

I accept responsibility for payment in full for services rendered on the day of examination. If my insurance is accepted and does not reimburse the doctor's

office, I understand I am responsible for payment. Exam fees are considered medical services and are therefore not refundable.

_____________________________________________________________________________________

Signature of Patient or Parent/Legal Guardian

Eye & Health History ________ Eye History: Have you ever been diagnosed with any of the following?

Cataract Y N Diabetic Retinopathy Y N Retina Defects Y N

Macular Degen. Y N Dry Eye Y N Retina Degen. Y N

Glaucoma Y N Eye Infection/allergy Y N Lasik or RK Y N

Diabetes Y N Inflammation Y N Lazy eye Y N

Have you ever had any eye surgeries? If yes, please list:____________________________________________________________________

Do you use any eye drops? If yes, what do you use them for and how often?__________________________________________________ What kind of contacts have you worn in the past? [ ] Disposable [ ] Toric [ ] Hard/Gas Perm [ ] Conventional Yearly

Name of contact lens brand? When was the last time you wore your contacts?____________________

How often do you replace your contact lenses?______________________ Do you sleep in your contacts?___________________________

________________________________________________________________________________________________________________________________

Eye Concerns: Are you experiencing any of the following eye/vision concerns?

Redness Y N Blurred Vision Y N Poor night vision Y N

Burning Y N Eyestrain Y N Night Glare Y N

Itching Y N Eye Pain Y N Double Vision Y N

Tearing Y N Severe light sensitivity Y N Total loss of Vision Y N

Discharge Y N Headache Y N Flashes/Floaters Y N

When was your last eye exam? How old are your glasses? Sunglasses?_________________________

________________________________________________________________________________________________________________________________

Health History:

Cancer Y N Gastrointestinal Y N Diabetes Y N

Ear/nose/throat Y N Kidney Disease Y N Thyroid Y N

Neurological Y N High Blood Pressure Y N Anemia Y N

Anxiety/Depression Y N STD-Herpes/chlamydia Y N Cholesterol Y N

Cardiovascular Y N Muscle/Joint/Bone Pain Y N Allergy/Immune Y N

Respiratory Y N Skin Y N HIV/Aids Y N

If you answered YES to any of the above questions or have any condition not listed, please explain:______________________________

___________________________________________________________________________________________________________________

Please list any medications you are currently taking:______________________________________________________________________

___________________________________________________________________________________________________________________

Do you have any sensitivity/allergy to any medications?____________________________________________________________________

Social History This information is strictly confidential. However, you may discuss this portion with the doctor if you prefer.

Do you drink alcohol? Y N [ ] Occasional [ ] 1 per day [ ] 2-3 per day [ ] 4+ per day

Do you use tobacco products? Y N [ ] Occasional [ ] 1/2 pack per day? [ ] 1 pack per day [ ] 1+pack per day

Do you use illegal drugs? Y N If yes, please list:_____________________________________

FEMALES ONLY:

Pregnant________Y_______N

Nursing_________Y_______N

________________________________________________________________________________________________________________________________

Family History: Please indicate: F(Father) M(Mother) B(Brother) Si(Sister) S(Son) D(Daughter)

Cancer Y N Heart disease Y N Retinal Detach Y N ____

Kidney disease Y N High blood press Y N Glaucoma Y N

Diabetes Y N Cataract Y N ____

Thyroid disease Y N ____ Macular Degen. Y N ____

We are proud to introduce the latest in retinal imaging, the Optomap. It is painless, quick

and the doctor’s preferred method of monitoring the health of your eye. This instrument will

enhance our ability to detect and monitor retinal defects associated with common systemic

diseases such as hypertension, diabetes, high cholesterol, and thyroid problems. Through this

digital imaging of the retina, we can observe early changes in the eye relating to glaucoma,

cataracts, and macular degeneration. Optomap can detect debilitating or potentially fatal

disorders that can be present in the retina.

This technology can be used without dilation, and will be a permanent part of your medical

records. There are no side effects with this test.

This technology is our preferred way of monitoring the eye over time.

By the time you have symptoms affecting your vision, it is typically too late to prevent

permanent sight damage. We care about your vision and want to be sure we actively

monitor your eye; the optomap retinal image is the best way to do this.

There is a nominal fee of $29 to perform this procedure. This includes dilation if the doctor

deems necessary.

o Yes, I would like to have the Optomap done today

o No, I would like to have my eyes dilated today. I understand that my near vision will be blurry

and I will be light sensitive for 4-6 hours.

o I would like to discuss this with Dr Lee

Print Name: __________________________________________________ Date: ___________________

Patient/Guardian Signature: ______________________________________________________________

Notice of Privacy Practices for Accurate Family Vision

This Notice describes how medical information about you may be used and disclosed and

how you can get access to this information. Please review it carefully.

Your protected health information (PHI) 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. We will obtain your written authorization

for uses and disclosures of your PHI that are not identified in this Notice or are not otherwise permitted by applicable law.

You may revoke an authorization at any time by sending us a written request however we are unable to retract previous

disclosures.

We May Use and Disclosure Your PHI WITHOUT Your Written Authorization For The Purpose Of:

• Treatment- Examples include scheduling and reminders of appointments; examinations, case management or

care coordination; prescribing/ordering of glasses, contact lenses, vision aides or medications and notification

of order status; or to recommend treatment alternatives or other health-related products or services.

• Payment-Examples include acquiring payment guarantor/insurance information; processing bills or claims;

and collecting unpaid balances.

• Health Care Operations-Examples include financial or billing audits; internal quality assurance including patient

satisfaction surveys; personnel decisions; participation in managed care plans; legal defense; business planning; and

outside storage of our records.

Other Uses and Disclosures That Do NOT Require Written Authorization

• As Required by Law – we will disclose PHI when required to do so by federal, state or local law.

• Public Health Activities- for example contagious disease reporting, investigation or surveillance; and notices to and

from the FDA regarding drugs or medical devices.

• Victims of Suspected Abuse, Neglect or Domestic Violence- PHI may be disclosed to the appropriate government

authorities.

• Health Oversight Activities- such as audits, medical licensing, investigations, inspections or licensure.

• Judicial and Administrative Proceedings- such as in response to subpoenas or court orders

• Law Enforcement- such as disclosures about a suspected crime victim; to identify or locate a suspect, fugitive, material

witness, or missing person; or about a crime committed in our office.

• Coroners, Medical Examiners and Funeral Directors- to identify a deceased person; to determine the cause of death

or to allow funeral directors to carry out their duties.

• Organ and Tissue Donation- to facilitate organ, eye or tissue donation and transplantation, disclosures may be made to

organizations that are involved in organ or tissue donation.

• Research - when approved by an institutional review or privacy board that has reviewed the research proposal and its

privacy protocols. Even without approval, we may permit researchers to look at records to help them identify patients

who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy

of any PHI.

• To Avert a Serious Threat to Health or Safety- PHI may be disclosed to protect others and will only be made to

someone who may help prevent the threat, including the target.

• Specialized Government Functions- such as the protection of the president or high ranking officials; lawful national

intelligence activities; military purposes as required by military command authorities; the evaluation and health of

members of the foreign service; in law enforcement custodial situations to provide health care or protect the health and

safety of others.

• Workers' Compensation- as required by law to workers' compensation or similar authorized programs.

• 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

Use and Disclosures of PHI to Family, Friends or Personal Representatives Unless you object, we may share relevant PHI with your family, close friends or personal representatives who are involved in

your health care or payment of your health care. We may also notify them of your location or general condition. If you are

not present or are incapacitated, we may use or disclose relevant PHI when, in our professional judgment, it is in your best

interest.

Specific Uses and Disclosures That REQUIRE Your Written Authorization

• Marketing Activities – other than face-to-face communications or promotional gifts of nominal value requires, we

may not use or disclose your PHI for marketing of products or services without your written notification IF we

receive payment by third parties whose products or services are described. The written authorization must inform

you that we are receiving compensation.

• Sale of Health Information. We do not currently sell or plan to sell your health information and we must seek your

written authorization prior to doing so.

Your Rights Regarding Your PHI:

• Right to Request Restrictions on Disclosures. You may send our office a written request to restrict or limit the PHI we

use or disclose for treatment, payment, or health care operations or to limit the PHI we disclose to family members or

friends involved in your care. We are not required to agree to all such requests. However, we must agree to requests

to restrict disclosure of PHI to a health plan if the disclosure is for the purpose of carrying out payment or health care

operations; if it is related to services that you have paid in full (e.g. out-of-pocket and without any third party

contribution or billing); and is not otherwise required by law.

• Right to Receive Confidential Communication. You may request that we communicate with you about medical

matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work.

Send a written request that specifies how or where you wish to be contacted to our office. We will accommodate

reasonable requests.

• Right to Inspect and Copy. You have a right to inspect and copy PHI that may be used to make decisions about your

care or payment for your care. This includes medical and billing records, other than psychotherapy notes. You may

request a copy of your electronic health records in electronic format. All requests must be made in writing. Contact us

for a copy of our authorization form. If copies of your records are requested, we may charge you a reasonable fee based

on the cost of labor, supplies and mailing/delivery fees.

• Right to Amend. If you feel that PHI we have is incorrect or incomplete, you may send a written request, including the

reason for the amendment, to our office.

• Right to an Accounting of Disclosures. You may request a list of certain disclosures of PHI, made within the past 6

years, for purposes other than treatment, payment and health care operations or for which you provided written

authorization. Send a written request that includes the time period requested and how you would like the report delivered

(paper or electronic) to our office.

• Right to a Paper Copy of This Notice. To obtain a paper copy of this notice send a written request to our office.

Our Duties We are required by law to: maintain the privacy of your PHI, give you this Notice of our duties and privacy practices

regarding PHI information to notify affected individuals following a breach of their unsecured PHI and abide by the terms of

the Notice currently in effect. If you have any questions please contact our office.

Changes to This Notice: We reserve the right to change this Notice and make the new Notice provisions apply to PHI we

maintain. A copy of our current notice will be posted in our office and copies will be available by request.

Complaints: If you believe your privacy rights have been violated, you may submit a written complaint to our office or with

the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint.

Please direct any questions or requests to: Amy M. Lee, O.D.

Accurate Family Vision

3570 S. Val Vista Dr. #104

Gilbert, AZ 85297

Ph: (480) 899-2381

Fx: (480) 899-1039

Medical vs. Vision insurance explanation

Most people have vision insurance and medical insurance. They are very different in terms of the

services they cover and it is important for our patients to understand those differences. Vision coverage (VSP,

Spectera, EyeMed, Davis, ect….) is mainly designed to determine a prescription for glasses and is not

equipped to deal with complex medical conditions and/or diagnosis. It does allow for screenings of

conditions, but once they are determined, then medical insurance is filed on those services. When a medical

condition is present (such as diabetes, cataracts, dry eye, floaters, etc.) it is necessary to file the visit with your

major medical carrier (BCBS, Aetna, UHC, Cigna, etc.) and the co-pays for that insurance will apply. Insurance

carriers set these rules and our office is required to follow them. In most cases, there is no way to know prior

to the examination which type of insurance our office will be able to file for you.

1. If you have ANY problems or complaints that MAY be attributable to a medical condition which requires a

more in-depth investigation and additional medical decision-making to rule out any underlying eye

disease, we will accordingly bill your MEDICAL insurance, NOT you vision plan. These include, but are not

limited to:

• New or sudden blurry vision • Flashes or floaters • Dry or itchy eyes • Eyestrain or double vision

• Eye pain or redness • Headaches • Loss of vision

2. There are a variety of systemic conditions that can profoundly and permanently affect a patient’s vision

that require a more in-depth investigation, which may include additional testing, follow up visits, and

reports to your primary care physician. This type of examination is NOT covered under “vision” plans,

and we will bill your MEDICAL insurance, NOT your vision plan. These include, but are not limited to:

• Diabetes • Hypertension • Thyroid disease

• Lupus or autoimmune disease • Diseases resulting in use of high risk

medications like Placquenil 3. If you have previously been diagnosed by another eye doctor for any eye issues that require medical

decision-making, treatment or management, we will bill your MEDICAL insurance, NOT your vision plan.

These include, but are not limited to:

• Cataracts • Amblyopic/lazy eye • Glaucoma/previous diagnosis of high eye

pressure

• Macular or retinal disease • History of eye surgery

We make every effort to be on every major carrier for your convenience and we will file those claims for

you. In the event that we do not take you insurance we will provide you with an itemized receipt so that you

may file with your carrier for reimbursement. If you have any question, please let us know.

I understand the document above and authorize Dr. Lee and Accurate Family Vision Pllc. to file my

insurance by the above guideline

Signature: ___________________________________________ Date:____________________