Patient Form

Phone (cell/hm)

Email

Date of Birth

Social Security #

Referred By

Occupation

Employer

Routine Vision Insurance:

ID #

Medical Insurance:

ID #

Group #

Insurance Phone #

Primary's Date of Birth:

Primary's Social Security # or ID:

Date of last eye exam:

What type?

Reason for visit today:

Do you or anyone in your immediate family have a history of the following:

Social History (smoking, drinking, recreational drugs) :

If so, frequency per week :

TESTING

FINANCIAL RESPONSIBILITY AGREEMENT

This form is consent from the patient or guardian to allow Chacko Vision PLLC to file benefits on your behalf. Please note that your insurance provider may not cover some services rendered.Iagree to assume responsibility for full payment pending any remaining balance that is not covered by my insurance carrier.I hereby authorize Chacko Vision PLLC to file my vision and/or medical benefits on my behalf,and therefore, I authorize my insurance carrier to direct payment of benefits to this office.

Signature:

Date:

If patient is a minor, relationship to patient :

NOTICE OF HIPAA PRIVACY POLICY

This form is posted in the office, and we will gladly provide you with a copy of this notice if you would like to keep one for your personal records. This notice describes how your personal health record information may be used or disclosed and how you may gain access to this information. Examples of uses of your health record information include patient recall, prescription verification or request, and for co-management with another health professional. Signing below indicates that you have been made aware of our privacy practices.

Signature

Date

If patient is a minor, relationship to patient :

FINANCIAL RESPONSIBILITY AGREEMENT

NOTICE OF HIPAA PRIVACY POLICY

Texas State Optical – Eagle Ranch