Patient Information

Thank you for choosing Valley Eye Associates for your eye care needs. Please complete this form. If you have any questions or concerns, please do not hesitate to ask for assistance. We will be happy to help you.

Sex
 
 
Would you like to receive text confirmations?

Do you prefer to receive calls at:

Race
Marital Status
Student?
 
Are you the Guarantor (person financially responsible)?
 
Guarantor Relationship to Patient *

Medical Insurance Information

Patient Medical History and Review of Systems

Chief Complaint:

How can we help you today? In this space, please briefly tell us any signs and symptoms you are experiencing.(Medical insurance will only cover your visit if there is a medical reason for the exam such as loss of vision, headaches, eye redness, eye pain, floaters, dry eye, eye itching or burning, glaucoma, cataracts, etc)

History of Present Illness:

Location

Which eye has the problem?

Quality

Does the problem cause vision loss or blur?

Context

Did the problem occur suddenly or gradually?

Severity

How severe is the problem?

Modifying Factors

Is it worse at any specific distance?

Duration

How long does it last?

Timing

How long has the problem been occurring

Associated Symptoms

Are there associated symptoms?

Previous Interventions

Does anything help the problem?

Are you thinking of getting GLASSES today?
Are you thinking of getting CONTACTS today?
Do you currently wear glasses?

When do you wear your glasses?

Glasses choices

Have you ever worn contacts?
Are you interested in wearing contact lenses?

What style are you interested in?

Contact lens choices

Do you work at a computer or video display terminal?

Please check any of the following conditions that apply to you:

Please list current medications:

Please check ‘yes’ or ‘no’ for each question and write in any essential information:

Past Ocular History

Glaucoma
Cataracts
Macular Degeneration
Diabetic Eye Disease
Retinal Detachment
Lazy Eye
Eye Surgery
Laser Treatments
Eye Injury
Chemo/Radiation
Severe Ocular Pain
Sensitivity to Light
Floaters or Spots
Flashes of Light
Poor Distance Vision
Poor Near Vision
Eye Infection or Disease
Double Vision
Eye Burn, Itch, or Water
Eye Strain

Family Ocular/Medical History

Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment
High Blood Pressure
High Cholesterol
Diabetes
Thyroid Problems
Heart Disease
Cancer

Social History

Smoking
Alcohol

Review of Systems:

Please check ‘yes’ or ‘no’ for each question and write in any essential information:

Constitutional -- Do you CURRENTLY have...

Flu
Fever
Fatique
Headache
Recent Weight Change

Ear, Nose, Throat

Hearing Problems
Sinus
Throat

Cardiovascular

Chest Pain
Palpitations
High Blood Pressure
High Cholesterol
Heart Failure
Pacemaker
Heart Attack
Angioplasty/Bypass
Valve Disease
Carotid Artery Disease

Respiratory

Shortness of Breath
Asthma
Emphysema
Cough
Bronchitis
Pneumonia
Tuberculosis

Hematologic

Anemia
Sickle Cell
Bleeding Abnormality
Elevated Cholesterol

Musculoskeletal

Joint Pain
Rheumatoid Arthritis
Back Pain
Fractures
Marfan's Syndrome
Ankylosing Spondylitis

Endocrine

Thyroid
Diabetes

Genitourinary

Prostate Problems
Kidney Stones
Hysterectomy

Neurological

Stroke
Weakness
Seizure
Multiple Sclerosis

Skin

Rash
Itch
Lesion
Growth/Tumors

Psychiatric

Dementia
Alzheimer's
Depression
Anxiety
Schizophrenia
Bipolar

Gastrointestinal

Heartburn
Bowel Problems
Inflammatory Bowel Disease
Gall Bladder Problems
Hepatitis

Immunology

Immune Deficiency
Lupus
Sjogren's
HIV Exposure
Cancer
STD Exposure

Authorization:

I certify that I have read and understood the above information to the best of my knowledge. I certify that the above questions have been accurately answered to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health. I authorize the doctor to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such eye care to third party payers and/or health practitioners

Agreement of Responsibility

WAIVER OF RESPONSIBILITY

I understand there are risks associated with using my own frame and that Valley Eye Associates is not responsible for any damage done during adjustments or insertion of new lenses.

FINANCIAL POLICY-SIGNATURE ON FILE FORM

We make every effort to keep down the cost of your medical care.

  • All fees are due the same day services are rendered or that the materials are ordered.
  • We accept the following forms of payment: Cash, Checks, Master Card, Visa, American Express, and Discover.
  • The patient who seeks care is responsible for the payment of all fees.
  • The person bringing the child into the office is responsible for the payment of all fees.
  • Additional fees for administrative services apply. These fees may include, but are not limited to, fees for medical records. as allowed by law, fees for non-covered services rendered and fees for the completion of forms you may request.
  • If an appointment is cancelled with less than 24 hours’ notice, a cancellation fee will be applied to the patient’s account.
  • If an attorney's services are required or if it is necessary to resort to small claims court, the patient will be required to pay the attorney's fees and the costs of court in addition to paying the amount due or ordered by the court.

PATIENTS WITH THIRD PARTY PLANS

I authorize my third party plan to pay Valley Eye Associates directly. If this is not permitted by my policy then send the check made out to Valley Eye Associates at the following address:

Valley Eye Associates
219 Old Hook Road
Westwood, NJ07675

I authorize Valley Eye Associates to file complaints on my behalf if my third party carrier does not properly handle my claim. In order to ensure payment of my claim, I authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.

PATIENT CONSENT FORM

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my 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 a treatment, both directly and indirectly.
  • Obtain payment from third party payers.
  • Conduct routine healthcare operations, such as quality assessments and physical certifications.

I have been informed by Valley Eye Associates and the Notice of Privacy Practices (see forms below) which contains a more detailed description of the uses and disclosures of my health information. I have been given the right to review and sign 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 to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that Valley Eye Associates restricts how my private information is used or disclosed to carry out treatment, payment, or health care options. I also understand that Valley Eye Associates is not required to agree to my request restrictions, but if Valley Eye Associates does agree then it is bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, excluding the extent in which Valley Eye Associates has already taken action relying on this consent.

Payment Policy

Patients who have insurance coverage that Valley Eye Associates participates with:

Valley Eye Associates participates with most insurance companies, but each plan varies by employer and insured. Please know your plan. Co-payments are due and payable at the time of your office visit. Deductibles, co-pays, co-insurances, and/or other balances that are your responsibility will be billed to you once these amounts are determined. If you are a member of an HMO, you are required by your plan to obtain a referral prior to your medical examination here.

If your plan requires a referral and you have not obtained one, your examination may need to be rescheduled.

You must present your insurance card at the time of your visit. If you do not have your insurance card your examination may need to be rescheduled.

Patients who have insurance coverage that Valley Eye Associates does not participate with:

You will be required to pay out of pocket at the time services are rendered. Please contact the physician and/or the office manager to discuss a payment plan, if necessary.

Patients who are not covered by insurance:

We require payment at the time services are rendered. Please contact the physician and/or the office manager to discuss a payment plan, if necessary before seeing the doctor.

Patients, who fail to provide accurate insurance information at the time services are rendered, will have seven (7) days to provide Valley Eye Associates the accurate insurance information. Failing to do so will result in full financial responsibility.

In an effort to provide you with flexible payment arrangements, we have expanded our payment policy.

Payment Arrangements are requested at the time of your visit.

We offer the following payment options:

Acceptable Payment Methods

Please make your choice and type your name below. If none of the above apply, please see the office manager. Thank you.

Our office is fully approved and accredited user of the Visa and Master Card Health Care Program which will enable you to use your Credit Card to automatically cover amounts not paid by your insurance. You may also choose a comfortable amount to be automatically billed to your Credit Card on a monthly basis.

I authorize the release of information to determine liability for payment and/or to obtain reimbursement. I understand that if my account is not paid directly, I am responsible for the full amount and may be charged all costs including attorney/collection agency fees incurred with collection of the amount due.

I authorize the release of any medical information necessary to process claims and the release of payment to Valley Eye Associates or the physician rendering services.