New Eye Care Patient Online Forms

Patient Information

First Name Mi Last Name
(Jr, Sr, etc)

Nickname Birth Date SS# --

Sex M F Martial status S M D W Email

Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTenesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWiskonsinWyoming Zip

(Phone) Home# Work# etc. Cell#

Employer Occupation

Emergency Contact

Name (First) Mi Last

Relationship

(Phone) Home# Work# etc. Cell#

Contact Preference

Email Home Phone Cell Phone Text/Cell Phone
Mother's Maiden Name Patient Birth State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTenesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWiskonsinWyoming

Name of Spouse/Parents (if child) Employer
Names and ages of other family members who are patients in our office:

How did you hear about our office?

Johnson Optometric Associates Website Phone Book Patient Refferal Insurance Company
Other

Insurance information (Please present card(s) to receptionist)

Insurance Responsible Party

Name Birth Date SS# --

Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTenesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWiskonsinWyoming Zip

Payment Information

Payment Policy: Payment in full is expected at the time professional services are rendered and/or materials are ordered. We are happy to file for insurance payment when applicable. A charge of 1.5% per month will be added to all accounts 30 days past due. Initial _________________

Failure to pay balances in the allotted time will result in patient incurring additional costs of collection including, but not limited to attorney or legal fees, collection agenees and finance charges.
Initial _________________

Acknowledgment

If insurance is fifed on my behalf, 1 authorize my insurance benefits to be paid directly to Johnson Optometric Associates, P.A. Initial _________________

I agree that unless Johnson Optometric Associates, P.A. and my insurer have a prior agreement, 1 am personally responsible for all non-covered services, co-pays and deductibles. Initial _________________

I authorize the release of medical information to insurance carriers or other physicians if it is deemed necessary by my optometrist for financial or consultative purposes. Initial _________________

Signature __________________________ Date ________________________

Responsible Party(Parent/Guardian of Minors)

Name Birth Date SS# --

Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTenesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWiskonsinWyoming Zip

Effective date of notice: 04/01/03
NOTICE OF PRIVACY PRACTICES
Johnson Optometric Associates, P.A.

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.

We respect our legal obligation to keep health information that identities you private. We are obligated by law to give you notice of our privacy practices. This notice describes how we protect your health information and what right you have regarding it.

TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

The most common reason why we use or disclose your health information is for treatment, payment or health care operations, Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; testing or examining your eyes: prescribing glasses, contact lenses, or eye medication and faxing them to be filled; showing you low vision aids, referring yon to another doctor or clinic for eye care of low vision aids or services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or vision care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or though a collection agency or attorney). “Health care operations" mean those administrative and managerial functions that we have to do in order to run our o Dice. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records,

We routinely use your health information inside our office for these purposes without any special permission, if we need to disclose your health information outside of our office for these reasons, we will ask you for special permission.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION

In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:

• When a state or federal law mandates that certain health information be reported for a specific purpose;
• For public health purposes, such as contagions disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;
• Disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
• Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
• Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
• Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime, to provide information about a crime at our office; or to report a crime that happened somewhere else;
• Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or issue donations;
• Uses or disclosure for health related research;
• Uses and disclosures to prevent a serious threat to health or safety;
• Uses or disclosures for specialized governmental functions, such as for the protect ion of the president or high ranking officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
• Disclosures of de-identified information;
• Disclosures relating to workers' compensation or other similar programs;
• Disclosures of a "limited data set” for research, public health, or health care operations;
• Incidental disclosures that mean unavoidable by-product of permitted uses or disclosures;
• Disclosures to 'business associates' who perform health care operations for us and who commit lo respect the privacy of your health information.

Unless you object, we will share also relevant information about your eye care with your family or friends who are helping you with your eye care.

APPOINTMENT REMINDERS

We may call or write to remind you of scheduled appointments, or that it is time lo make a routine appointment, We may also call or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you an appointment on a post card, and/or call you. It may be necessary to leave a reminder message on your home answering machine or with someone who answers your phone if you are not home.

OTHER USES AND DISCLOSURES

We will not make any other uses or disclosures of your health information unless you sign a written "authorization form”. The content of an “authorization form" is determined by federal Law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it's your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form, or you can use of ours.

If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosures. If you do sign one, you may revoke it at anytime unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the bottom of this notice.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

The law gives you many rights regarding your health Information. You can:

• Ask us in restrict our uses and disclosures for purposes of treatment (except emergency treatment}, payment or health care operations. We do not have to agree lo do this, but if we agree, we must honor restrictions that you want. To ask for a restriction, send n written request to the office contact person at the address or fax shown at the beginning of this notice.
• Ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different Address, or by using email to your personal email address, We will accommodate these requests if they are reasonable. and if you pay us for any extra cost, if you want to ask for confidential communications, send a written request to the office contact person tit the address or fax at the beginning of this notice
• Ask to see or to get photocopies of your health information, by law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or sixty if the information is stored off-site). You may have to pay for photocopies in advance, If we deny your request, we will send you a written explanation, and Instructions about how to get an impartial review of our denial. If one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to preview or get photocopies of your health information, send a written request to the office contact person at the address or fax shown at the beginning of this notice.
• Ask us to amend your health information if you think it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons tor amendment, to the office contact person at the address or fax shown at the beginning of this notice.
• Get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You arc entitled to one such fist per year without charge. If you want more frequent lists you will have to pay for them in advance; We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office contact person at the address or fax at the beginning of this notice.
• Get additional paper copies of this notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written request to the office contact at the address or fox at the beginning of this notice.

OUR NOTICE OF PRIVACY PRACTICES

By law, we must abide by the terms of this Privacy Practice until we choose to change it. We reserve the fight to change this notice at any time as allowed by law, If we change this notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our web site.

COMPLAINTS

If you think that we have not properly respected the privacy information, you are free to complain to us or the US Dept, of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to Office Manager either at the address or fax at the beginning of the notice. If you prefer, you can discuss your complaint in person or by phone.

FOR MORE INFORMATION

If you want more information about our privacy practice's, call or visit the office at the address at the beginning of this notice.

This privacy statement represents the policies of Dr. Robert L, Johnson, Dr, Rick L, Hartman, Dr, Robert S, Hammond, and all the staff of Johnson Optometric Associates, P.A.

CONSENT FOR DILATION

During the course of an examination, the Doctor may determine It is necessary to dilate the pupils of your eyes. This allows for a more thorough examination of the health of the Inside of the eye. We recommend a dilated examination for: 1) all new patients, 2) patients at risk for, or with pre-existing eye disease, or 3) routinely every 3-5 years, unless contraindicated.

To dilate the pupil, eye drops must be administered. Once your pupils are dilated, it is common to be sensitive to light, a symptom that is usually alleviated with sunglasses. If you do not have any sunglasses, a disposable pair can be provided for you by the receptionist. Another common symptom is blurred vision, especially at near. It will require 4-6 hours for your vision to return to normal. During this time you must exercise caution when walking down steps, driving a vehicle, operating dangerous machinery, or performing other tasks that may present a risk of injury. If you have any transportation needs, please Jet us know so they can be arranged.

YES	NO
I understand the side effects and benefits of papillary dilation, and I consent to have the procedure performed	I understand the side effects and benefits of papillary dilation, and I do not consent to have the procedure performed
Patient’s Name: Signature ______________ Date

DIGITAL RETINAL IMAGING

Digital retinal imaging Is a new computer based technology that allows instant viewing of the inside of the eye by the doctor and the patient. Like dental x-rays this technology establishes a superior medical record we can compare to with past and future images. This may allow earlier diagnosis of eye diseases such as glaucoma, diabetic eye disease, muscular degeneration and other heath threatening conditions.

Johnson Optometric strongly recommends this procedure be performed in conjunction with all complete eye examinations.

YES	NO
I want to have digital images taken of the back of my eyes. I understand there is a $30.00 charge that is not covered by insurance.	I do not want digital retinal Imaging today
Patient’s Name: Signature ______________ Date

HIPPA Privacy statement

This privacy statement represents the policies of Dr. Robert L. Johnson, Dr. Rick L. Hartman, Dr. Robert S. Hammond, Dr. Andrew R. May and the staff of Johnson Optometric Associates, P.A..

HIPPA COMPLIANCE ACKNOWLEDGEMENT OF RECEIPT

I acknowledge that I received a copy of the privacy statement of Johnson Optometric Associates, P.A.

Notice of Privacy Practice Date:

Patient’s Name: Signature ___________________

FAMILY HISTORY	YES	NO	RELATION
Blindness
Cataract
Gloucoma
Macular Degeneration
Retinal Detachment
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Stroke
Thyroid Disease
Other

Please explain condition(s)

PERSONAL HISTORY	YES	NO
Eyes
Cataracts
Eye Surgey / Eye Injury
Gloucoma
Lazy Eye / Crossed Eye
Macular Degeneration
Retinal Detachment
Other
Ears, Nose, Mouth, Throat
Hematological/Lymphatics
Cardiovascular (Heart/Vessels)
High Blood Pressure
Heart Disease
Respiratory (Lunge/Breathing)
Asthma
Chronic Bronchitis
Gastrointestinal (Stomach, intestines)
Genltourlnary (Genital/Kidney/Bladder)
Musculoskeletal (Arthritis)
Integumantary (Skin/Breast)
Neurological (Stroke/Numbness)
Psychiatric
Endocrine
Diabetes
Thyroid
Allergic and immunological

Please explain condition(s)

List current medication(s):

List any medications you are allergic to:

List any surgeries (and date) you have had:

Occupation Tobacc Use (type/amount):
Hobbies: Alcohol Use:
Computer Usage: Substance Abuse:
Primary Physician: Pharmacy:
Date of last Tetanus shot:

Print patient's name
Today's date:

Dr. Robert L. Johnson Dr. Rlck L. Hardman Dr. Rohert S. Hammond Dr. Andrew R. May

Johnson Optometric Associates P.A. 1340 N. Main Street Fuquay Varina, NC 27526 Ph: 919.552.3181 Fa×: 919.552.0197

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

Please be advised that our staff cannot speak with anyone that is not listed on this form. This includes spouses, children and caregivers.

Print Patient Name Date of Birth

I am authorizing the personnel at Johnson Optometric Associates to leave medical information and test results with others if I am not available.

I do not wish to have my information released to anyone besides myself.

OR

I authorize that my information can be left with my spouse/significant other or parents

Name of person

Other: I authorize that my information can be left with:

Name / Relationship

Name / Relationship

Signature: ________________________________________ Date:

Relationship to patient: