New Patient Paperwork

Patient Name:

Date of Birth:

Email

Status:

Authorization of Disclosures

I hereby authorize Wallingford Eye Care to communicate my health care and/or billing to the following family members/personal representatives (PR):

Name:

Relationship to patient:

Name:

Relationship to patient:

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of protected health information (PHI). The individual is also provided the right to request confidential communication or that a communication of PHI be made by an alternative means; such as sending correspondence to the individual’s office instead of the individual’s home. The privacy rule generally requires healthcare providers to take reasonable steps to limit use or disclosure of any requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by the individual. Healthcare entities must keep records of PHI disclosures within your records, if completed properly, will constitute an adequate record.

Note: Uses and disclosures for TPO may be permitted without prior consent in an emergency

Insurance Information

Vision Insurance:

Member ID #:

Medical Insurance:

Member ID #:

Agreement & Release:

I certify that I, and/or my dependent(s) have insurance coverage with the above stated company(s). And assign directly to Wallingford Eye Care Center all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance; I authorize the use of my signature on all insurance submissions. Wallingford Eye Care Center may use my health care information and may disclose such information to the above-named insurance company(s) and their agents for the purpose of obtaining payment for services and determining insurance benefits for the benefit payable for related services.

Collections Notice

If at any point your account balance becomes past due over 90 days, it will accrue a $1.00 late fee every 30 days thereafter in addition to a non-negotiable $45.00 fee for our services. If this balance continues to be unpaid, your account will be sent to an outside collection agency in an attempt to collect the outstanding debt. Signing below confirms that you have read and understand this notice.

Patient Signature

Date:

Notice of Privacy Policies & Consent (HIPAA)

In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this information in order to treat you, obtain payment for our services and to conduct health care operations involving our office.

The Notice of Privacy Practices you have been given describes the uses and disclosures in detail. You are free to refer to this notice at any time before you sign this form. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and services provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow up care from another health care professional. Similarly, the use and disclosure of your health information for purposes of payment includes (1) our submissions of your health information to a billing agent or vendor for processing claims or obtaining payment; (2) our submission of claims to third-party payers or insurers for claims review, determination of benefits and payment; (3) our submission of your health information to auditors hired by third-party payers and insurers; and (4) other aspects of payments described in our Notice of Privacy Practices. Our Notice of Privacy Practices will be updated whenever our privacy practices change. You can get an updated copy here at the office.

When you sign this consent document, you signify that you agree that we can and will use and disclose your health information to treat you, obtain payment for our services, and to preform healthcare operations. You also signify that you have received a copy of our Notice of Privacy Practices.

You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment or healthcare operations but as described in our Notice of Privacy Practices, we are not obligated to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.

I have read this document and understand it. I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations. I acknowledge that I have received the Notice of Privacy Practices from Wallingford Eye Care Center.

Patient Signature

Date

If signing as a personal representative of the patient, describe the relationship to the patient and the source of authority to sign this form:

Relationship to Patient

Print Name

Source of Authority

Contact Lens/Lasik Exam fees

It is our foremost responsibility as your eye care professional to monitor your ocular health as a contact lens wearer or a patient who has had Lasik performed. In order for us to do this successfully, a corneal topography is required and performed every year in addition to your yearly eye exam. A corneal topography will be performed on all of our contact lens and Lasik patients. The charge is $69.00. Unfortunately, your insurance company will not cover this charge.

For Lasik and contact lens patients, a corneal topography test provides detailed 3D maps of the cornea's shape and curvature and enables detection of corneal diseases, and irregular corneal conditions, such as swelling, scarring, abrasions, deformities, and irregular astigmatisms. We use topography to assure that the Lasik treatment was uniform and effective. If the cornea has an irregular surface, patients may complain of glare, halos and/or blurred vision despite reading 20/20 on the eye chart.

*If you are interested in contact lenses, the fitting fees start at $279 (which includes the corneal topography which is non-refundable). This fee can change depending on your prescription.

**If you are a current contact lens wearer and you, or the doctor feels you need to be re-fit into another type or brand of contact lens, a re-fitting fee will apply. Re-fitting fees start at $100.00 and vary depending in the complexity of the individual case. Please consult our staff or your attending doctor.

We are proud to offer you the highest level of technology and care here at Wallingford Eye Care Center. If you have any questions or concerns regarding these procedures, please feel free to contact the office at (203) 265-5152.

Patient Name

Patient or Guardian Signature

Today’s Date

No Show Policy

Thank you for trusting your medical care to Wallingford Eye Care Center. When you schedule an appointment with Wallingford Eye Care Center we set aside enough time to provide you with the highest quality care. Should you need to cancel or reschedule an appointment please contact our office as soon as possible. This gives us time to schedule other patients who may be waiting for an appointment. Please see our No Show policy below:

  • Effective May 11, 2023 new and established patients who fail to show to their scheduled appointment and have not contacted our office will be considered a No Show and charged a $50 fee


We understand there may be times when an unforeseen emergency occurs and you may not be able to keep your scheduled appointment. Please call our office to cancel or reschedule the appointment.

I have read and understand the No Show Policy and agree to its terms.

Signature (Parent/Legal Guardian)

Relationship to patient

Printed Name

Date

Please tell us how you use your eyes in the pursuit of your lifestyle

Name

Date

What is your occupation?

Hours per day on technology:

Check all that apply:

What types of vision correction do you currently use? (Check all that Apply):

Do you wear Contact Lenses?

If not, are you interested in wearing them?

How far is the reading or close work material from you? (Check all that apply)

How would you describe the lighting where you do most of your reading?

Do you experience back, neck, or shoulder discomfort when using a computer?

Have you experienced any issues with glare or eye strain in the daytime, night time (halos around headlights), or while using technology?

What activities or hobbies do you engage in? (Check all that apply.)

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