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      Patient Information

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      Insurance Information

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      Eye-Related History

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      Medical History

    • 5

      Lifestyle

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      Terms & Conditions

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    Patient Information

    Patient Information

    First Name*

    Middle

    Last Name*

    Nickname

    Address*

    Apt No.

    City*

    State*

    Zip Code*

    Cell Phone*

    Home Phone

    Email*

    Preferred Method of Contact*

    Birthday*

     

     

    Gender Identity

    Birth Sex

    Preferred Pronoun

    Occupation/Student Grade

    Employer/School

    Marital Status

    Name of Parent or Guardian (if applicable)

    Billing Information

    Is the billing information different from the patient contact information above?

    Address*

    Apt No.

    City*

    State*

    Zip Code*

    Cell Phone*

    Home Phone

    0%

    Vision Insurance Information

    Do you have Vision Insurance?

    Vision Insurance Company Name

    Member ID

    Insurance Policy Group

    SSN (only required for VSP patients)

    Are you the primary vision insurance policy holder?

    Enter Details about the Primary Vision Insurance Policy Holder Below

    Name of Primary Policy Holder

    Relationship

    Primary Policy Holder's Social Security Number

    Birth Sex of Primary Policy Holder

    Birthday*

     

     

    Primary Policy Holder's Employer/School

    Address

    Apt No.

    City

    State

    Zip Code

    Phone Number

    Medical Insurance Information

    Do you have Medical Insurance?

    Medical Insurance Company Name

    Member ID

    Insurance Policy Group

    Are you the primary medical insurance policy holder?

    Do you have a secondary medical insurance?

    Secondary Insurer Name

    Insurer ID

    Insurance Policy Group

    Are you the secondary medical insurance policy holder?

    Enter Details about the Primary Medical Insurance Policy Holder Below

    Name of Primary Policy Holder

    Relationship

    Primary Policy Holder's Social Security Number

    Birth Sex of Primary Policy Holder

    Birthday*

     

     

    Primary Policy Holder's Employer/School

    Address

    Apt No.

    City

    State

    Zip Code

    Phone Number

    Enter Details about the Secondary Medical Insurance Policy Holder Below

    Name of Secondary Policy Holder

    Relationship

    Secondary Policy Holder's Social Security Number

    Birth Sex of Secondary Policy Holder

    Birthday*

     

     

    Secondary Policy Holder's Employer/School

    Address

    Apt No.

    City

    State

    Zip Code

    Phone Number

    20%

    Eye History

    What is the reason for your appointment today?

    Do you currently have any of the following conditions?

    Please describe any eye surgeries and/or trauma if applicable (include dates)

    When was your last eye exam?

    Where was your last eye exam?

    Retinal Evaluation

    A retinal evaluation is required for all exams. Please select one of the following options*:
    *Exception: Children under 5 years old require dilation to accurately assess early childhood development.

    Optomap Info - Preferred and recommended by doctors ($39 copay)

    • No eye drops

    • No light sensitivity

    • No blurry vision. Patients are safe to drive and return to work.

    • Fast, allowing for shorter exam time.

    • Comprehensive and advanced - detects diseases often missed on dilation

    Dilation Info

    • Side effects include blurry vision and light sensitivity for 6-8 hours.

    • Temporary burning and stinging sensation.

    • For safety, a driver is recommended after the exam.

    • Please allow at least 30 minutes for the dilation drops to take effect.

    Family Eye History

    Do you wear contacts?

    Contact Lens Wearers Only

    A yearly contact lens prescription & evaluation for renewal is not included as part of a comprehensive eye exam. We can add the contact lens prescription & evaluation service to your exam. Please select an option below:

    What solution do you use?

    Do you have backup glasses?

    How often do you sleep in your contacts?

    How often do you replace your contacts?

    40%

    Medical History

    Prescription Medications:

    Drug Allergies:

    Over-the-Counter Medications and Supplements:

    Please describe any injuries or surgeries you have had:

    Current Primary Care Physician:

    Last Visit:

    Reason for Visit:

    Primary Care Clinic Name

    Do you have any of the following medical conditions?

    Other (please specify):

    Family Medical History

    Other Medical Conditions in Family

    60%


    Social History

    Hobbies & Daily Activities

    Smoking/Tobacco Status

    80%

    Policies, Consent, Submit Data

    NOTICE OF PRIVACY PRACTICES
    THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
    PLEASE REVIEW IT CAREFULLY.THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
    OUR LEGAL DUTY

    We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. In the event we make a material change in our privacy practices, we will change this Notice and provide it to you. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

    USES AND DISCLOSURES OF HEALTH INFORMATION

    We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

    Treatment: We may use or disclose your health information to an optician, ophthalmologist or other healthcare provider providing treatment to you for: a) the provision, coordination, or management of health care and related services by health care providers; (b) consultation between health care providers relating to a patient; (c) the referral of a patient for health care from one health care provider to another; or (d) recall information.

    Payment: We may use and disclose your health information to obtain payment for services we provide to you. This may include: (a) billing and collection activities and related data processing; (b) actions by a health plan or insurer to obtain premiums or to determine or fulfill its responsibilities for coverage and provision of benefits under its health plan or insurance agreement, determinations of eligibility or coverage, adjudication or subrogation of health benefit claims; (c) medical necessity and appropriateness of care reviews, utilization review activities; and (d) disclosure to consumer reporting agencies of information relating to collection of premiums or reimbursement.

    Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include things such as quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

    Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

    Marketing Health Products or Services: We will not use your health information for marketing communications without your prior written authorization. We may provide you with information regarding products or services that we offer related to your health care needs. We will never sell your health information without your prior authorization.

    To You, Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so or, if you are not able to agree, if it is necessary in our professional judgment.

    Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

    Required by Law: We may use or disclose your health information when we are required to do so by law, including judicial and administrative proceedings.

    Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

    National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

    Appointment Reminders and Treatment Alternatives: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters) or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

    PATIENT RIGHTS

    Access: You have the right to review or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.

    Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations, where you have provided an authorization and certain other activities, for the last 6 years, but not for disclosure made prior to April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

    Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

    Alternative Communication: You have the right to request in writing that we communicate with you about your health information by alternative means or to alternative locations. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

    Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.

    Electronic Notice: If you receive this Notice on our a Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

    QUESTIONS AND COMPLAINTS

    If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

    Contact Person: Tracy Ho
    Telephone: 505-892-8411 Fax: 505-375-4793
    E-mail: cov@swcp.com
    Address: 4025 Jackie Road SE, Rio Rancho, NM 87124

    Please sign below indicating that you have read and agree to our policies and click the SUBMIT button to complete your online forms. Thank you!

    Patient/Guardian Signature




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