New Patient Form If you are a new patient, please use the form below. 1Patient Information2Insurance Information3Payment Authorization4Notice of Privacy Practices5Patient History6Dry Eye Center7Health Testing Today's Date* MM slash DD slash YYYY How did you hear about our office? Is there someone we may thank? First Name* Last Name* Name Prefix? Mr. Mrs. Ms. Miss Rev Dr. Sex Male Female Patient's Social Security #* Date of Birth* Month Day Year Status* Single Married Dating Widow Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Are you currently employed?* Yes No HiddenEmployer InformationEmployer Occupation PhoneEmployer Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Billing of Insurances Most people have vision insurance and medical insurance. They are very different in terms of the services they cover and it's important for our patients to understand those differences. Vision coverage (VSP, Eyemed, Spectera, etc.) 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 screening 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, deductible, and co-insurance for that insurance will apply as well as the non-covered service. Insurance carriers set these rules and our office is obligated 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. 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 your insurance we will provide you with an itemized receipt so that you may file with your carrier for reimbursement. If you have any questions, please let us know. Contact Lens Prescriptions I acknowledge and agree that if I am fit with contact lenses, once the prescription is finalized, I will be provided with a signed copy of my prescription. I consent to receiving either a physical hard copy or electronic email copy of my prescription.Agree to Terms I have read and agree to the billing of insurancesHiddenused for conditionalWill someone else be responsible for bill payment?* Yes No HiddenPerson responsible for bill paymentGuarantor - (Person responsible for bill if other than patient) Guarantor's PhoneRelationship to Patient Guarantor's Employer Guarantor's Employer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country In Case of emergency Contact or Secondary contact (person not living with patient)First Name* Last Name* Relationship Emergency Contact Phone*Primary Care Physician Primary Care Physician Phone Medical Insurance Information(If you need Prior Authorization from your family physician, please obtain it prior to your visit)Do you have medical insurance? Yes No Hiddenused for conditionalPrimary Medical Insurance Carrier Medical Insurance Policy Number Medical Insurance Group Number Primary Policy Holder Information Same as patient? Primary Policy Holder's First Name Primary Policy Holder's Last Name Primary Policy Holder's SSN Primary Policy Holder's DOB Month Day Year Policy Holder's Employer or Retiree's former employer Hiddenused for conditionalDo you have a secondary medical insurance? Yes No HiddenSecondary Medical Insuranceused for conditionalSecondary Medical Insurance Carrier Policy Number Group Number Primary Policy Holder's Name Social Security Number Date of Birth Month Day Year Policy Holder's Employer or Retiree's former employer Hiddenused for conditionalDo you have vision insurance? Yes No HiddenVision Insuranceused for conditionalVision Insurance Provider Vision Insurance Policy Number Vision Insurance Group Number Primary Policy Holder Information Same as patient? Primary Policy Holder's First Name Primary Policy Holder's Last Name Social Security Number Date of Birth Month Day Year Policy Holder's Employer or Retiree's former employer Hiddenused for conditionalBilling of Insurances Most people have vision insurance and medical insurance. They are very different in terms of the services they cover and it's important for our patients to understand those differences. Vision coverage (VSP, Eyemed, Spectera, etc.) 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 screening 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, deductible, and co-insurance for that insurance will apply as well as the non-covered service. Insurance carriers set these rules and our office is obligated 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. 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 your insurance we will provide you with an itemized receipt so that you may file with your carrier for reimbursement. If you have any questions, please let us know. Contact Lens Prescriptions I acknowledge and agree that if I am fit with contact lenses, once the prescription is finalized, I will be provided with a signed copy of my prescription. I consent to receiving either a physical hard copy or electronic email copy of my prescription.Agree to Terms* I have read and agree to the billing of insurancesPatient/Parent or Guardian Signature*Today's Date* MM slash DD slash YYYY It is the policy of Clarity Advanced Eyecare to require PAYMENT AT TIME THE SERVICES ARE PROVIDED. By signing below I am stating that I understand this policy. I understand that in the event of a returned product, Clarity Advanced Eyecare may charge a restocking fee that will vary based on the company's expenses/costs. If my account balance remains unpaid after receiving a 60 day statement, I will be responsible for that balance plus an additional 1.5% monthly interest on the amount due. However, if the small balance on my account is under $25 I should only expect to receive a statement every 6 months. Remember that insurance is a form of reimbursement made on behalf of the patient to the doctor for service rendered and NOT A SUBSTITUTE for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to know what your insurance pays and to pay any deductible amount, co-insurance or any other balance not paid for by your insurance. I hereby instruct and direct Insurance Company to pay by check made out and mailed to: Clarity Advanced Eyecare, 970 S. Old Woodward Ave., Birmingham MI 48009 or If my current policy prohibits direct payment to doctor, I hereby also instruct and direct you to make out the check to me and mail it as follows: Clarity Advanced Eyecare, 970 S. Old Woodward Ave., Birmingham, MI 48009. For the professional or medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment. Any products returned to Clarity Advanced Eyecare may be assessed a restocking fee. To the extent necessary to determine liability for payment and to obtain reimbursement, I authorize disclosure of portions of my patient records, as per HIPPA policy. I hereby assign all medical and or surgical benefits, to include major-medical benefits to which I am entitled including Medicare, private insurance and other health plans to Clarity Advanced Eyecare. I also authorize the Doctor to deposit checks received on Patient's account when made out to the Patient. This assignment will remain in effect until revoked by me in writing. A photo copy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I understand that I am responsible for all services not covered by insurance plans. I hereby authorize said assignee to release all information necessary to secure the payment.Patient/Parent or Guardian Signature*Today's Date* MM slash DD slash YYYY Please read the NOTICE OF PRIVACY PRACTICES FORM that is attached here.Agree to Terms* I understand and accept the policies as noted in said formPatient/Parent or Guardian Signature*Today's Date* MM slash DD slash YYYY Patient HistoryReview of SystemsCheck all that Apply Constitution (Cancer, Developmental Disabilities, Fatigue) Ear/Nose/Throat (hearing loss, sinus) Neurologic (MS, epilepsy, stroke, autism) Psychiatric (depression, anxiety, ADHD) Cardiovascular (high blood pressure, heart disease) Respiratory (asthma, emphysema, sleep apnea) Gastrointestinal (heartburn, crohn's, ulcers) Genitourinary (kidney disease, prostate, STD, pregnant) Musculoskeletal (arthritis, fibromyalgia, gout) Skin (eczema, rosacea, psoriasis) Endocrine (diabetes, thyroid, hormonal dysfunction) Blood/Lymphatic (anemia, blood disorder) Immune Disorder (allergies, rheumatoid, lupus, sjogren's) None of the above Please provide more details about your Constitution symptomsPlease provide more details about your Ear/Nose/Throat symptomsPlease provide more details about your Neurologic symptomsPlease provide more details about your Psychiatric symptomsPlease provide more details about your Cardiovascular symptomsPlease provide more details about your Respiratory symptomsPlease provide more details about your Gastrointestinal symptomsPlease provide more details about your Genitourinary symptomsPlease provide more details about your Musculoskeletal symptomsPlease provide more details about your Skin symptomsPlease provide more details about your Endocrine symptomsPlease provide more details about your Blood/Lymphatic symptomsImmune Disorder (allergies, rheumatoid, lupus, sjogren's)Do you use any EYE medications?* Yes No List any Eye MedicationsDo you use any other medications?* Yes No List all Other MedicationsDo you have any medication allergies?* Yes No List any Allergy MedicationsOther Allergies* Hayfever Ragweed Dust Latex Pets Bees Nuts Shellfish None Eye Surgeries, Injuries, or Trauma Yes No Please list any Eye Surgeries, Injuries, or TraumaHave you ever been diagnosed with: Glaucoma Cataracts Keratoconus Macular Degeneration Amblyopia Retinal Tear/Detachment Strabismus (Lazy Eye) None of the above Other Please describe Do you smoke?* Yes No How much? Do you consume alcohol?* Yes No How much? Immediate Family HistoryCheck all that apply Diabetes Cancer Glaucoma Macular Degeneration High Blood Pressure Other Systemic Retinal Detachment Other Ocular None of the above Dry Eye CenterDry Eye Disease is a common reason for patients to visit eye doctors. Please take a moment to thoughtfully complete this questionnaire. 1. Report the frequency of your symptoms by checking the appropriate box: 0 = never 1 = sometimes 2 = often 3 = constantDryness, Grittiness, or Scratchiness* 0 1 2 3 Soreness or Irritation* 0 1 2 3 Soreness or Irritation* 0 1 2 3 Burning or Watering* 0 1 2 3 Eye Fatigue* 0 1 2 3 2. Report the severity of your symptoms using the rating list below: 0 = No Problems 1 = Tolerable - not perfect, but not uncomfortable 2 = Uncomfortable - irritating, but does not interfere with my day 3 = Bothersome - irritating and interferes with my day 4 = Intolerable - unable to perform daily tasksDryness, Grittiness, or Scratchiness* 0 1 2 3 4 Soreness or Irritation* 0 1 2 3 4 Burning or Watering* 0 1 2 3 4 Eye Fatigue* 0 1 2 3 4 3. Please check if you have experienced the above symptoms Today Within Last 3 days Within past 3 months 4. Do you use eye drops for lubrication? Yes No How many? 5. Do you have fluctuating vision that improves when you blink? Never Sometimes Frequently Always 6. Have you been told you have blepharitis? Yes No 7. Have you been treated for a stye? Yes No HEALTH TESTING NECESSARY FOR PROPER PATIENT CARE In order to provide PREVENTATIVE eye health evaluations and PRESERVE your sight with EARLY DETECTION of systemic (body) disease and ocular (eye) disease, the following tests must be performed on all patients annually. Your vision insurance does not cover the cost of these vital tests, yet they are necessary for proper eye health examinations. These health tests are being offered to you at a reduced fee as follows: RETINAL PHOTOGRAPHY Taking YEARLY colored photographs of the inside or back of the eye is much like a dentist x-raying your mouth annually. The photos of the retina will document the internal health of the eyes and allow for accurate yearly comparisons. This allows your doctor to detect early eye health changes and can dictate treatment if necessary. iWELLNESS Like an MRI of the eye, the iWellness Exam reveals ocular anatomy and signs of disease in exquisite detail. This breakthrough technology allows your doctor to examine, with unprecedented clarity, structure that is INVISIBLE using traditional methods. This unique technology can help detect potentially vision threatening diseases such as Glaucoma, Macular Degeneration, and others in their earliest stages, thus improving outcomes.The fees for these necessary services are due today and are indicated below.* Yes I choose to have both RETINAL PHOTOGRAPHY AND iWELLNESS performed at a fee of $60. Yes I choose to have RETINAL PHOTOGRAPHY performed at a fee of $30. Yes I choose to have iWELLNESS performed at a fee of $35. No, I choose to decline these health tests. I understand the risk involved with declining. First Name* Last Name* Today's Date* MM slash DD slash YYYY Your E-Signature*PhoneThis field is for validation purposes and should be left unchanged.
