Health History Form

HIPAA
I understand that in an attempt to protect the privacy of my identifiable health information, Edgewater Eyecare, LLC has established a Privacy Policy and guidelines for Privacy Practices within their office. This information details the use and/or disclosure of information contained in my personal medical/optometric records kept for the purpose of diagnosis, treatment, payment and health care operations. In accordance with HIPAA Regulations, a copy of the Notice of Privacy Practices of Edgewater Eyecare, LLC has been made available to me while in the office today. Should I choose to have a personal copy, one will be given to me at no charge. By signing below, I understand and acknowledge the Notice of Privacy Practices of Edgewater Eyecare, LLC.*
I understand that in an attempt to protect the privacy of my identifiable health information, Edgewater Eyecare, LLC has established a Privacy Policy and guidelines for Privacy Practices within their office. This information details the use and/or disclosure of information contained in my personal medical/optometric records kept for the purpose of diagnosis, treatment, payment and health care operations. In accordance with HIPAA Regulations, a copy of the Notice of Privacy Practices of Edgewater Eyecare, LLC has been made available to me while in the office today. Should I choose to have a personal copy, one will be given to me at no charge. By signing below, I understand and acknowledge the Notice of Privacy Practices of Edgewater Eyecare, LLC.
I agree to the privacy policy.
Patient Name*
Date*
MM slash DD slash YYYY
Signature*
I understand that the Practice may wish to contact me for purposes related to my treatment such as to remind me of appointments, leave messages, or to discuss financial/billing business, or to indicate other necessary contacts.
Please Select One*
- Yes, I authorize the Practice to contact me at the contacts (phone #s/email) I have provided. I understand and authorize the practice to leave me a voicemail message if I am unavailable.
- No. I do not agree to these contacts. Do not leave a message.
The following people may have access to my personal health information:
Name Relationship
Health History
Name*
First Last
Today's Date*
MM slash DD slash YYYY
S.S.N.
Date of Birth*
Month
Day
Year
Address*
Street Address Address Line 2 City State ZIP Code
Cell
Home
Work
Occupation
Employer
Email
Is the patient a minor?*
- Yes
- No
Parent/Guardian Information
Parent/Legal Guardian's Name*
Date of Birth*
Month
Day
Year
S.S.N.
Insurance
Do you have Vision Insurance
- Yes
- No
Vision Insurance
Insurance company*
ID Number*
Insured Person’s Name*
Relationship
Policy Holder’s DOB*
Month
Day
Year
Policy Holder’s SSN*
Co-pays & Deductibles are required on date of service. We will bill your insurance but can’t assure payment. You are fully responsible for payment.
Do you have Medical Insurance*
- Yes
- No
Medical Insurance
Insurance company*
ID Number*
Insured Person’s Name*
Relationship
Policy Holder’s DOB*
Month
Day
Year
Policy Holder’s SSN*
Co-pays & Deductibles are required on date of service. We will bill your insurance but can’t assure payment. You are fully responsible for payment.
Do you have Supplemental Secondary Insurance*
- Yes
- No
Supplemental Secondary Insurance
Insurance company*
ID Number*
Insured Person’s Name*
Relationship
Policy Holder’s DOB*
Month
Day
Year
Policy Holder’s SSN*
Co-pays & Deductibles are required on date of service. We will bill your insurance but can’t assure payment. You are fully responsible for payment.
Authorization To File Health Insurance Claims
I understand and agree that by allowing Edgewater Eyecare, LLC to file insurance on my behalf does not absolve or excuse me from my financial obligations to pay for all services; and/or glasses or contacts my dependents or I may receive. Failure of my insurance company to make payment on my behalf, whether due to deductible, pre-existing conditions, non-covered services, or any other reasons for which payment is denied, will be PAID BY ME.By my signature below, I have read and agree with the terms stated above. I authorize the release of any medical or other information necessary to process this claim. I authorize payment of medical benefits to be made directly to Edgewater Eyecare, LLC.Accounts delinquent over 90 days will be turned over to Network Services Collection Agency. In addition to the amount owed to Edgewater Eyecare, LLC you will be responsible for paying fees to the collection agency as well.*
I understand and agree that by allowing Edgewater Eyecare, LLC to file insurance on my behalf does not absolve or excuse me from my financial obligations to pay for all services; and/or glasses or contacts my dependents or I may receive. Failure of my insurance company to make payment on my behalf, whether due to deductible, pre-existing conditions, non-covered services, or any other reasons for which payment is denied, will be PAID BY ME.
By my signature below, I have read and agree with the terms stated above. I authorize the release of any medical or other information necessary to process this claim. I authorize payment of medical benefits to be made directly to Edgewater Eyecare, LLC.
Accounts delinquent over 90 days will be turned over to Network Services Collection Agency. In addition to the amount owed to Edgewater Eyecare, LLC you will be responsible for paying fees to the collection agency as well.
I understand and agree
Date*
MM slash DD slash YYYY
Signature (signature of parent, if patient is a minor)*
Medical History
Who is your family physician:
Your Gender
- Male
- Female
Last Eye Exam:
Month
Day
Year
By whom:
List any medications you are currently taking
Medication Prescription or over-the-counter Dose and Frequency
List any medications you are allergic to:
Are You Pregnant?*
- Yes
- No
Are You Nursing?*
- Yes
- No
Do You Wear Glasses*
- Yes
- No
Do you wear contact lenses?*
- Yes
- No
Your General Health
Have you ever had or do you currently have...
- Allergies
- Heart Disease
- High Blood Pressure
- Cancer
- Diabetes
- Gastrointestinal Disease
- Headaches
- Kidney Disease
- Anemia
- Skin Problems
- Muscle Pain
- Joint Pain
- Arthritis
- Psychiatric Illness
- Respiratory / Lung Disease
- Asthma
- Emphysema
- Thyroid Disease
- Lupus
- Stroke
- Seizure
- HIV / AIDS
- STD
- Other
If other, please explain*
Family Health History
Diabetes*
- Yes
- No
Relationship*
High Blood Pressure*
- Yes
- No
Relationship*
Cancer*
- Yes
- No
Relationship*
Arthritis*
- Yes
- No
Relationship*
Glaucoma*
- Yes
- No
Relationship*
Blindness*
- Yes
- No
Relationship*
Cataracts*
- Yes
- No
Relationship*
Cross Eyes*
- Yes
- No
Relationship*
Lazy Eye*
- Yes
- No
Relationship*
Macular Degeneration*
- Yes
- No
Relationship*
Eye Health
Do you have any of the following?
- Glaucoma
- Cataract
- Macular Degeneration
- Retina Detachment
- Amblyopia
- Strabismus
- Blurred Distance Vision
- Blurred Near Vision
- Double / Distorted Vision
- Eye Strain / Headache
- Glare / Light Sensitivity
- Tired Eyes
- Dryness
- Sandy or Gritty
- Redness
- Excessive Tearing
- Foreign Body Sensation
- Mucus / Discharge
- Loss of Vision
- Floaters or Flashes
- Night Vision Problems
- Other
If other, please explain*
Social History
Do you smoke?*
- Yes
- No
Amount?*
Years*
Do you consume alcohol?*
- Yes
- No
Amount?*
Use Street Drugs
- Yes
- No
List any eye trauma or eye surgeries you have had.
List all other major injuries, surgeries or hospitalizations you have had.
COVID-19 Pandemic Essential Eye Exam and Treatment Consent Form
Please read the following statements and check following statements to indicate your agreement. If you cannot positively affirm to all of these questions, you will be asked to postpone or reschedule your visit to a later date.*
- I do not currently, nor have I had in the last two weeks, a fever, cough, sore throat, loss of smell/taste or other cold symptoms.
- To the best of my knowledge, I do not have, nor have I been in direct contact with someone who has confirmed diagnosis of COVID-19 or a presumptive positive COVID-19 test result in the last 30(thirty) days.
- Neither I, nor anyone living in my immediate household, have traveled outside of the state in the last 30 days.
I understand that before and during my visit to Edgewater Eyecare, Dr. Johneen Gilich and her staff are taking reasonable precautions to limit any exposure I may have to the Covid-19 virus and acknowledge that infection with the virus could lead to serious illness. I further understand that there are certain inherent risks of infection associated with an eye exam during a pandemic. By signing this Consent Form, I acknowledge that there is a risk of exposure to Covid-19 , during a visit to the clinic & undergoing an eye exam, that cannot be eliminated one hundred percent; and I assume & accept responsibility for that risk, as I deem my eye exam essential to the maintenance of my eye health & vision. I agree that should I, or someone with whom I come in contact, become infected with the Covid-19 virus, I will not seek to hold Edgewater Eyecare LLC, Dr. Gilich or any members of the staff, their landlord, insurers , or anyone acting on behalf of the Clinic responsible, and release them from any loss, injury or damage resulting from a Covid-19 infection.*
I understand that before and during my visit to Edgewater Eyecare, Dr. Johneen Gilich and her staff are taking reasonable precautions to limit any exposure I may have to the Covid-19 virus and acknowledge that infection with the virus could lead to serious illness. I further understand that there are certain inherent risks of infection associated with an eye exam during a pandemic. By signing this Consent Form, I acknowledge that there is a risk of exposure to Covid-19 , during a visit to the clinic & undergoing an eye exam, that cannot be eliminated one hundred percent; and I assume & accept responsibility for that risk, as I deem my eye exam essential to the maintenance of my eye health & vision. I agree that should I, or someone with whom I come in contact, become infected with the Covid-19 virus, I will not seek to hold Edgewater Eyecare LLC, Dr. Gilich or any members of the staff, their landlord, insurers , or anyone acting on behalf of the Clinic responsible, and release them from any loss, injury or damage resulting from a Covid-19 infection.
I agree to the privacy policy.
Legal Name*
Date*
MM slash DD slash YYYY
Signature*

Medication	Prescription or over-the-counter	Dose and Frequency

Name	Relationship

Health History Form

HIPAA

Health History

Parent/Guardian Information

Insurance

Vision Insurance

Medical Insurance

Supplemental Secondary Insurance

Authorization To File Health Insurance Claims

Medical History

Your General Health

Family Health History

Eye Health

Social History

COVID-19 Pandemic Essential Eye Exam and Treatment Consent Form