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Patient Information


Patient Information

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Gender:
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Address


Address

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Is it okay to contact you by email?
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Emergency Contact Information


Emergency Contact Information

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Insurance Information


Insurance Information

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Is this patient a minor?
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Does the patient have a legal representative?
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Authorization


Authorization

I authorize Haas Vision Center to release any information regarding my examination and/or treatment to any other physician, insurance company or health organization as required.
I authorize any physician, hospital or medicare care facility to provide all information regarding any health history and/or treatment to Haas Vision Center.
I authorize payment directly to Haas Vision Center for the surgical and/or medical benefits, if any, otherwise payable to me under the terms of my insurance.
I understand that I am ultimately responsible for payment for services rendered even though it may be covered by medical insurance, Workers Compensation, or a private agreement with another party.
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Financial Policy


Financial Policy

Haas Vision Center is a dedicated medical and surgical practice. Therefore, we do not accept any vision plan insurance. Your exam today WILL be billed under your medical insurance. Please understand that vision insurance will only cover routine vision problems such as near or far-sighted vision, eyeglasses and contacts; vision insurance will not cover medical eye conditions.
Haas Vision Center makes every effort to ensure that we participate with your health insurance. Health insurance companies are continually offering new plans with different networks. Unfortunately, the insurance companies do not always let us know if we are in network; therefore, it is impossible to know for certain that we participate with your insurance. It is the patient's responsibility to ensure we are in network before being seen by Dr.Haas. If your insurance claim comes back as out of network, you will be responsible for all charges dictated by your insurance company.

Please understand that our financial policies are established to assure the financial resources needed to maintain this medical office for all our patients. We will work with you regarding your financial responsibility.

  • We must emphasize that as a health care provider our relationship with you, not your insurance company.
  • Your insurance is a contract between you, your employer, and the insurance company. We bill your insurance company as a courtesy to you, the patient.
  • You are responsible for knowing what your co-payments, deductibles and/or co-insurnace is with your insurance provider. Please contact your insurance company and/or your employer's human resources department with regards to your benefit questions

If you have health insurance with which we participate:

  • We will bill your insurance claim for you.
  • We expect any required co-payment at time of service.
  • We expect payment of the deductible and coinsurance to be paid in full after we have issued you a statement to be paid within 30 days unless prior arrangements have been made.

If you are uninsured or we do not participate with your insurance, payment for total charges are due on the day of your appointment unless prior arrangements have been made.

Late Cancellation/No Show Policy


Late Cancellation/No Show Policy

Due to the increased demand for appointment times, it has become necessary to implement a late cancellation/no show policy for office visits. 24 HOUR NOTICE IS REQUIRED FOR ALL CANCELLATIONS. If a patient appointment has been confirmed and the patient fails to keep the appointment, it will be documented in the patient chart and a fee of $35.00 will be assessed to the patient's account.
I have read and accept the terms of this financial policy:
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Information and Consent for Refraction


Information and Consent for Refraction

It may be important to your care to perform a vision test called a "refraction" to check for your BEST vision today. A refraction is when the examiner determines the prescription required for the patient's eyeglasses by evaluating the effectiveness of a series of lenses through which the patient is asked to view an eye chart. This is accomplished with a phoropter (refractor), a device that contains a range of lens powers that can be quickly changed, allowing the patient to compare various combinations when viewing the eye chart. A lens prescription is issued when the examination is complete.
Medicare, AARP and Medicare Advantage Plans DO NOT COVER refractions. If Medicare does not cover the refraction, neither will most other secondary insurances. The cost for your refraction is $50.00 which will be collected at check-out today.
Some private insurance plans will cover the cost of refractions. Therefore, we will bill your private insurance for the refraction. If the private insurance denies the refraction, we will send you a statement for the cost of the refraction ($50.00).
I understand that if I have a refraction today that the cost of the refraction will be as stated above.
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Information and Consent for Dilated Eye Examination


Information and Consent for Dilated Eye Examination

It may be important to your care today to dilate your eyes. Dilating eye drops are used to enlarge the pupils of the eye to allow the physician to obtain a better view of the inside of your eyes.
Dilation frequently changes for vision for a length of time which varies from person to person and may make bright lights bothersome. It is not possible for us to predict to what degree your vision will be affected. Driving may be difficult immediately after the examination. If you are concerned about these problems, you may wish to make alternative transportation arrangements, although a large number of patients do drive after dilation with the assistance of temporary sunglasses, which we can provide after your dilation.
I hereby authorize the physician and/or such assistants as may be designed by him to administer dilating eye drops. The eye drops are necessary to perform a complete exam of the retina and back of the eye. This may reveal the presence of a serious systemic condition as well as eye conditions.
I agree to have the dilation examination on every visit that Dr.Haas deems it necessary to conduct a complete examination of my eyes. I understand that if I decide not to have the dilated examination, I must sign another form revoking my consent for that visit only.
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HIPPA RELEASE OF INFORMATION


HIPPA RELEASE OF INFORMATION

Release of Information
This information may be released to:
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This Release of Information will remain in effect until terminated by me in writing.
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Receipt of Notice of Privacy Practice Written Acknowledgement Form


Receipt of Notice of Privacy Practice Written Acknowledgement Form

I have read/received/been presented with a copy of the Notice of Privacy Practices.
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Family Medical History


Family Medical History

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Have you ever had any surgical procedures before?
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Vision History


Vision History

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Do you OR any one in your family have any history of the following:
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How Did You Hear About Us?


How Did You Hear About Us?

Haas Vision Center would appreciate if you took the time to let us know how you heard about us.
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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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