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Patient History Form

Dear patient:
We welcome you to our practice and ask that you kindly complete all information on this form.
  • PATIENT INFORMATION

  • Date Format: MM slash DD slash YYYY
  • (check all that apply)
    SelfFamily
    Glaucoma
    Cataracts
    Diabetes
    High Blood Pressure
    Macular Degeneration
    Heart Problems
    Retinal Degeneration
    Stroke
    Thyroid Condition
    Crossed/Lazy Eyes
    Asthma/ Allergies
    Color Blindness
    Arthritis
    Tuberculosis
    HIV/Hepatitis
    Cancer
    Neuromuscular
    Blindness
    Other
  • (check all that apply)
  • (check all that apply)
  • INSURANCE INFORMATION


  • GUARANTOR
  • Date Format: MM slash DD slash YYYY
  • MEDICAL INSURANCE POLICY:
    As part of our services at this practice we are happy to assist you in determining the benefits of your individual policy and in collecting your reimbursement of insurance benefits for medical services. To avoid any misunderstandings please read the following statements carefully:
    1. The legal obligations of your insurance provider are between yourself and your provider, not between this practice and your provider.
    2. When your insurance provider (s) has settled your plan’s covered items, you will be notified by a monthly statement if there were any unpaid balances. Unpaid balances can include non-covered items or services, co-pays, deductibles, lapses, ineligibility or termination of coverage’s. Unpaid balances are the sole responsibility of the patient.
    3. To keep the cost of records and collections down any patient portion amounts on your order will be due at the time of service.
    4. I authorize the use of this form on all insurance submissions as well as authorizing the release of information to all my insurance companies as well as allowing the doctor to act as my agent to help me in obtaining payment from my insurance companies.
    5. I authorize payment to be made directly to the provider and permit a copy of this authorization to be used in place of the original.

    REFUND/RETURN POLICIES:
    No refund can be made on clinical procedures or services, including comprehensive eye examination, refraction, contact lens fitting, and medical office visits. Refunds for optical products, which include frames, lenses, and unopened boxes of contact lenses can only be made within 30 days of receiving the product, provided that the product is returned to the store without damage at the time that the refund is issued. Opened boxes of contact lenses are non-refundable. After the 30 days period, only 50% of the original payment made by the patient (private-pay or with insurance) can be issued back to the patient as store credit with the return of the product. 90 days after a product is dispensed, no refund, no exchange, no return can be made on any goods purchased at this store.

    CONSENT FOR TREATMENT:
    I hereby authorize Specs For Less to administer diagnostic and medical procedures as may be necessary for proper health care.
  • Date Format: MM slash DD slash YYYY
  • HIPAA CONSENT

    CONSENT TO USE AND DISCLOSE HEALTH INFORMATION
  • Permission to Use and Disclose My Health Information: By signing this form, I give Specs For Less permission to use and/or disclose my health information to provide treatment, obtain payment, and/or conduct health care operations.
    Right to Refuse: I have the right not to sign this consent. If I refuse to sign this consent, Specs For Less has the right to refuse to treat me. However, treatment required by law –such as emergency care– can be provided to me whether or not I sign this consent.
    Right to Review Notice of Privacy Practices: I have been provided with a copy of the Notice of Privacy Practices for Specs For Less which describes how Specs For Less may use and disclose my health information. I have the right to review this Notice before signing this consent.
    Changes to the Notice of Privacy Practices: Specs For Less may change the Notice of Privacy Practices as needed. I may obtain a current copy of the Notice of Privacy Practices for Specs For Less by contacting Specs For Less.
    Right to Request Restrictions on Use/Disclosure: I have the right to request that the usage of my protected health information by Specs For Less be restricted in how it is used and/or disclosed for the purpose of providing treatment, obtaining payment, and/or conducting health care operations. However, Specs For Less is not required to agree to any restriction that I request. If Specs For Less does decide to agree to my request, the use and/or disclosure of my health information by Specs For Less must be restricted as I requested. If I wish to request restrictions I can contact Specs For Less.
    Specs For Less will notify me on whether my restrictions have been accepted or declined.
    Right to Withdraw Consent: I have the right to withdraw this consent at any time. I must do so in writing by contacting Specs For Less at 1489 Forest Avenue, Staten Island, NY 10302. My withdrawal of this consent will not be effective for uses and/or disclosures that have already been made based on my prior consent. If I withdraw this consent, then Specs For Less may refuse to provide to me further treatment or follow-up, other than required emergency services.
    Effective Period: This consent is good unless and until I withdraw it in writing.
    References to “I” or “me”: References to “I” or “me” in this Consent include the individual for whom the signing party is authorized to sign. If I am signing this consent on behalf of another person, it is because I am that person’s parent, legal guardian, or agent under an active Power of Attorney for Health Care; and I am legally authorized to sign this Consent on behalf of that person.
  • Date Format: MM slash DD slash YYYY
  • FOR OFFICE USE ONLY

    Complete this section if this form is not signed and dated by the patient or an authorized representative for the patient.
  • Date Format: MM slash DD slash YYYY

North Shore
Info | 855-855-6039
South Shore
Info | 855-855-6042

Tottenville
Info | 855-855-7803
New Springville
Info | 855-855-3728

Keyport New Jersey
Info | 855-855-7804
Manhattan Third Avenue
Info | 855-855-4622

Specs For Less 2019 10 9×12 INSERT 2 11