Name

First Middle Last

Date of Birth

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

E-mail Address

(used for recall purposes)

Responsible party & relationship if patient is a dependent

How did you hear about us? (Examples: walk-in, referral, internet search, previous Costco exam, insurance)

Approx. date of last eye exam?

Location of last eye exam?

Main purpose of today’s visit?

Do you currently wear glasses?_

Do you currently wear contact lenses?

Are you interested in wearing contact lenses?

Lasik vision correction?

Ocular Health – please check any of the following that apply to you

Please list medications you are taking and what they are being taken for

Please list any significant medical conditions not listed above

Please list any medications that you are allergic to

Family History – please check any of the following that are in your direct bloodline

Diabetes
Glaucoma
Macular degeneration
Blindness
Other

Federal law requires you be made aware of your privacy rights regarding personal medical information. By signing you acknowledge that you have been offered a copy of the federal HIPAA privacy policies, and that
you have read and understand the exam fee policy sheet.

Optos Daytona

Dr. Lewis & Associatesoffers a state‐of‐the‐art digital scanning technology that allows us to view the inside of your eye without the use of dilation drops in most cases. >The OPTOMAP allows us to evaluate your retina for problems such as retinal tears, retinal detachments, retinal tumors, macular degeneration, hypertension, and diabetic retinopathy. This scanning system is completely safe for kids and adults and does not emit radiation like an X-ray.

Optomap exam advantages

1. No blurred vision

2. No light sensitivity

3. Images can be captured in 0.25 of a second

4. Permanent record of retina for future comparison

5. You can see your retina!

vs.

Dilated exam

1. Blurred near vision for 4 – 6 hours

2. Light sensitivity for 4 – 6 hours

3. 20-30 min longer office visit waiting for drops to work

4. No permanent digital record of retina

5. Only the doctor can see the retina

Optomap image showing retinal tear

Retinal image with a horseshoe tear that would be very difficult to detect without the Optomap. Problems such as retinal tears can occur without symptoms and potentially lead to retinal detachment and vision loss. Dr. Lewis and his associates have discovered retinal tears in numerous patients through the use of the Optomap. Prompt referral to a retinal specialist saved vision in each case

We recommend that ALL patients have a thorough examination of their retina during every routine eye exam.
Without the Optomap or the dilated examination, the doctor cannot fully assess the health of the back of your eyes.
There is an additional fee of $25 for the Optomap. In most cases, this procedure is not covered by insurance.

I elect to have an Optomap ($25) and understand it is not required but recommended by our doctors.
I prefer a dilated exam of my retina and I have been informed of the side effects listed above.
I do not wish to have either the Optomap or dilation performed, and understand that I am limiting my doctor’s ability to diagnose eye diseases that could lead to vision loss.
I wish to speak with the doctor first before making a final decision.

Exam Fees

Exams for Glasses are $80

Contact Lens Exams are $105 - $125 depending on the complexity of the fit. Patients with high astigmatism, patients needing monovision contact lenses, bifocal contact lenses, or gas permeable contact lenses are more complex. Contact lens exams include a glasses prescription.

New contact lens wearers will be charged a $30 fee for contact lens insertion and removal training.

Fees for medical eye office visits (such as “red eye” problems) can range from $85-$115 depending on the complexity of the diagnosis and treatment.

Follow-up Exam Policy
For Glasses Prescriptions: If you are unhappy with your new glasses prescription, please schedule an appointment within 60 days with the optometrist to assess the problem free of charge. If you return later than 60 days past the original exam, an office visit fee will apply. If you return 6 months past the original exam date, you will be assessed another full exam fee.

For Contact Lens Prescriptions: The contact lens exam includes all contact lens fitting related appointments for 60 days from the date of the original exam. If you need a follow-up and do not return to a scheduled appointment, you do NOT have a valid contact lens prescription. If you return 2-6 months after the original exam date, you will be assessed an additional fitting fee. If you return for a follow-up past 6 months, you will be assessed the full contact lens exam fee.

We require payment for services at the time of the examination.

Although we may be able to bill your insurance for some services, fees not paid by the insurance are ultimately the patient’s responsibility.

Notice of Privacy Practices

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. If you have any questions please contact our office. We are required by law to: Maintain the privacy of your protected health information, give you this notice of our duties and privacy practices regarding health information about you, and follow the terms of our notice that is currently in effect

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION:

Described as follows are the ways we may use and disclose health information that identifies you (Health Information, or PHI). Except for the following purposes, we will use and disclose Health Information only with your written permission. You may revoke such permission at any time by writing to us and stating that you wish to revoke permission you previously gave us.

Treatment We may use and disclose Health Information for your treatment and to provide you with treatment-related health care services. For example, we may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.
Payment. We may use and disclose Health Information so that we may bill and receive payment from you, an insurance company, or a third party for the treatment and services you received. For example, we may give your health plan information so that they will pay for your treatment. However, if you pay for your services yourself (e.g. out-of-pocket and without any third party contribution or billing), we will not disclose Health Information to a health plan if you instruct us to not do so.
Health Care Operations.We may use and disclose Health Information for health care operation purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the care you receive is of the highest quality. Subject to the exception above if you pay for your care yourself, we also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operations.
Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services.We may use and disclose Health Information to contact you and to remind you that you have an appointment with us. We also may use and disclose Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you. We will not, however, send you communications about health-related or non health-related products or services that are subsidized by a third party without your authorization.
Individuals Involved in Your Care or Payment for Your CareWhen appropriate, we may share Health Information with a person who is involved in your medical care or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort
ResearchUnder certain circumstances, we may use and disclose Health Information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. Before we use or disclose Health Information for research, the project will go through an approval process. Even without approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any Health Information.
Fundraising and Marketing Health Information may be used for fundraising communications, but you have the right to opt-out of receiving such communications. Except for the exceptions detailed above, uses and disclosures of Health Information for marketing purposes, as well as disclosures that constitute a sale of Health Information, require your authorization if we receive any financial remuneration from a third party in exchange for making the communication, and we must advise you that we are receiving remuneration.
Other Uses. Other uses and disclosures of Health Information not contained in this Notice may be made only with your authorization.

SPECIAL SITUATIONS:

As Required by Law We will disclose Health Information when required to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety We may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may help prevent the threat.
Business Associates We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract
Organ and Tissue DonationIf you are an organ donor, we may use or release Health Information to organizations that handle organ procurement or other entities engaged in procurement; banking or transportation of organs, eyes, or tissues to facilitate organ, eye or tissue donation; and transplantation.
Military and Veterans If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.
Workers' CompensationWe may release Health Information for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks. We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
Health Oversight Activities.We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits. If you are involved in a lawsuit or a dispute, we may disclose Health Information in response to a court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement We may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under limited circumstances, we are unable to obtain the person's agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors. We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties.
National Security and Intelligence Activities. We may release Health Information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others.We may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or to conduct special investigations.
Inmates or Individuals in Custody If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution.

YOUR RIGHTS: You have the following rights regarding Health Information we have about you:

Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in writing, to our office.
Right to Amend If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request, in writing, to our office.
Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of Health Information for purposes other than treatment, payment and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to our office.
Right to Request Restrictions.You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to our office. We are not required to agree to all such requests.. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
Right to Request Confidential Communication You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communication, you must make your request, in writing, to our office. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice please request it in writing.
Right to Electronic Records. You have the right to receive a copy of your electronic health records in electronic form.
Right to Breach Notification.
You have the right to be notified if there is a Breach of privacy such that your Health Information is disclosed or used improperly or in an unsecured way

CHANGES TO THIS NOTICE:

We reserve the right to change this notice and make the new notice apply to Health Information we already have as well as any information we receive in the future. We will post a copy of our current notice at our office. The notice will contain the effective date on the first page

COMPLAINTS:

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. All complaints must be made in writing. You will not be penalized for filing a complaint.

I acknowledge having been provided this Notice.

Patient/Guardian’s Signature

Date