Mosier Eye Center | Patient Information Form

At Mosier Eye Center, we provide the highest quality service to all our patients. Use the form below to request your appointment. Please indicate your preferred date and time. Please note that we will reach out to you first to confirm your appointment or to provide you with an alternative date. You may also call us to request an appointment. Thank you!

Full Name*

Street Address

City*

State / Province / Region

ZIP / Postal Code

Cell Phone*

Home Phone*

Work Phone

Email*

Date of Birth

Gender*

MaleFemale

Marital Status

Social Security Number

Primary Language

Occupation

Employer

Primary Care Physician

Primary Care Physician Address

Emergency Contact

Phone

Ethnicity

Race

Primary Insurance

Secondary Insurance

Vision Insurance

Primary ID / Policy #

Secondary ID / Policy #

Vision ID / Policy #

If policy subscriber / guarantor is other than the patient (minor)

Full Name*

Phone

Relationship

MOSIER EYE CENTER - Patient History Questionnaire
IMPORTANT: This questionnaire if to be reviewed at each appointment. Please answer all questions

Patient Demographics

Name*

Date of Birth

Phone*

Primary Care Physician

Phone*

Last Seen

Medical/Eye Information

How is your general health?

Do you have problems with any of these systems?

Type

Date of Diagnosis

Date of Last Tetanus Shot

Allergies to Medication

Do you take blood thinners?*

YesNo

Current Medications (Please Include Dosage) *

Family History

High Blood Pressure *

YesNo

Relation

Glaucoma *

YesNo

Relation

Macular Degeneration*

YesNo

Relation

Cataracts*

YesNo

Relation

Retinal Detachment*

YesNo

Relation

Diabetes*

YesNo

Relation

PATIENT RESPONSIBILITY

Agreement of Responsibility

I understand that professional services are rendered to the patient and that the patient is responsible for charges incurred for these services. Payment for annual deductibles and coinsurance may be collected at the time of service. I understand that I am financially responsible for charges not covered by my insurance company.

Consent to Treatment

I voluntarily consent to such care and treatment as prescribed by the physician as is necessary in his/her judgment.

Release of Information/ Assignment of Benefits

I authorize use of this form on all my insurance submissions and authorize release of information to process a claim to all my insurance companies. I permit a copy of this authorization to be used in place of the original. I authorize the provider to act as my agent in helping me obtain payment from my insurance companies I understand the provider does not accept responsibility for collecting my insurance claims or for negotiating a settlement on disputed claims. I assign all rights and claims for reimbursement of expenses allowable under my insurance plan and authorize payment directly to the provider for services rendered. I understand I will receive a monthly statement for any balance due from me.

I have read and fully understand the above statements.

PatientInitial/Parent for Minor

I confirm that that all information entered is true and correct and constitutes a legal signature that I acknowledge and agree to the terms and conditions. *

PATIENT CONSENT FORM

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow- up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
Obtain payment from third-party payers.
Conduct normal healthcare operations such as quality assessments and physician certifications.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

Patient Name*

Initial

Relationship to Patient

Date

I confirm that that all information entered is true and correct and constitutes a legal signature that I acknowledge and agree to the terms and conditions. *

Our Commitment to You

Our doctors are committed to diagnosing, managing, and treating eye diseases.

We develop individualized treatment plans to address each patient's unique eye condition.

Insurance Plans

WE ACCEPT MOST PPO MEDICAL PLANS
Anthem Blue Cross, Aetna, Blue Shield, Cigna,
United Healthcare, Medicare, St-Jude HMO,
St-Joseph and many more.

WE ARE A PROVIDER FOR
Blue Shield PPO Covered California
We are not a provider for Anthem PPO Covered CA

TYPES OF PAYMENT WE ACCEPT
Cash, Personal Checks, Debit Cards, Visa,
Master Card, Discover, and American Express.

WE ALSO OFFER CARE CREDIT.