REASON FOR VISIT: Please list CURRENT MEDICATIONS or MEDICATION ALLERGIES:
__Yearly general eye exam ___ allow Dr. to download med list __None
__Need more contacts __ none currently __Codeine
__Blurry vision at distance __Contact lens solution
__Blurry vision at near __Eye drops
__Pain or discomfort __Novocain
__Eyestrain __Penicillin
__Dryness / Burning / Itching __Sulfa
__Urgent condition __Other:
PATIENT ACKNOWLEDGEMENT
Health Insurance Portability and Accountability Act (HIPAA)
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The notice contains a patient rights section describing your rights under the law. You have the right to review our notice before signing this acknowledgement. The Notice of Privacy Practices is available to view in our office. If you would like to receive a copy of the notice, we are happy to email a copy to you. They are also available on our website. The terms of our notice may change. If we change our notice, you may obtain a revised copy by contacting our office.
If you wish for persons other than those released under normal operations as indicated in the notice to receive confidential information that is now protected under this law you must release them in writing. Parents or Guardians of minor children do not need to be released.
Please be aware that our staff has to follow federal law on information that we release by phone and we may at any time choose not to release information of any kind by phone if we feel that the person requesting information is not authorized or we feel the information may be too sensitive to release by phone.
By signing this form, you are acknowledging that Visionary Eye Care Professionals has made our Notice of Privacy Practices available to you for review and that we have offered you a personal copy.
Signature: ____________________________________________________ Date: ______________
Patient name (print): _________________________________________________
Relationship to patient: __________________________________________
ACKNOWLEDGEMENT OF OFFICE POLICIES AND FINANCIAL AGREEMENT
By signing this form, you are acknowledging Visionary Eye Care Professionals’ Office Policy and Financial Agreement. Personal copies are available upon request.
Signature: _________________________________________________ Date: _______________
