Returning Patient Information Form

Please join us in the effort to reduce the unnecessary waste of paper by filling out these history forms online. Every time this online form is used, it reduces paper waste by approximately 8 to 10 sheets of paper. Also, please read and review the Online HIPAA Privacy Policy, available on our Forms page. You will be required to acknowledge that you have reviewed the HIPAA Privacy Policy before your information can be submitted on the last page of this questionnaire.

Thank you for your efforts.

Filling out the following form now will help make your visit more punctual and thorough. Required areas to be completed are annotated with a red asterisk *

Step 1 of 5

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Insurance Information
Do you have:*
- Medical Insurance
- Vision Insurance
- Both Medical & Vision Insurance
- No Insurance
Please provide your insurance status for us.
Medical Insurance Information
Medical Insurance Company (if applicable)
Policy #
Type of Insurance Policy*
- HMO
- PPO
- Other
Please provide your insurance status for us.
Group #
Medicare #
Vision Insurance Information
Vision Insurance Company (if applicable)
Policy#
Vision Group#
Policy Holder Information
Policy Holder Name
Policy Holder's Date Of Birth
Policy Holder SS# (last four)
Relationship to Patient*
Policy Holder's Employer

Patient Eye History
Have you had any changes or problems since your last eye exam?*
- Yes
- No
If yes, please explain:*
General Health
Your Primary Care Physician:
Phone
Date of Last Medical Exam:
Height*
Weight*
Have you had any medical changes since your last exam?*
- Yes
- No
If yes, please explain:*
Are you taking any medications? If yes, please enter medications and what you use them for*
- Yes
- No
Medication Information
Pharmacy Information
Please provide us with your pharmacy name, location, and phone number in the event that we need to contact them regard any prescriptions that need to be ordered on your behalf.
Pharmacy Name
Pharmacy Location
Pharmacy Phone
Allergies
Please list any allergies that you may have
Medication Allergies:
Contact Lenses / Glasses
Are you currently having any problems with your current contacts or eyeglasses?

Meaningful Use
Meaningful Use is a government program to ensure that healthcare professionals are utilizing their Electronic Medical Records system efficiently to improve healthcare quality and patient safety. English Rows Eye Care understands that this is very personal and sensitive information. We want to ensure you that this information will only be used as part of the Meaningful Use objectives.
Preferred Language:*
- English
- Spanish
- Other
Race:*
Ethnicity*
Preferred Communication Methods:*
- Email
- Postal Mail
- Telephone

Authorization
- I have reviewed the information on this form and it is accurate to the best of my knowledge. I understand that this information will be used by the Doctor to help determine appropriate treatment. If there is any change in my medical status, I will inform the Doctor.
- I authorize my insurance company to pay English Rows Eye Care all insurance benefits otherwise payable to me for services and/or materials.
- I understand that a quote of eligibility and benefits from my insurance company is not a guarantee of payment. All benefits are subject to eligibility, medical necessity and the terms, conditions, limitations and exclusions of my health benefit plan at the time services are rendered and that I am financially responsible for all co-pays, co-insurance and non-covered charges.
- I authorize the use of this signature on all insurance submissions.
- I authorize English Rows Eye Care to release all information necessary to secure the payment of benefits.
- I acknowledge that I was offered/provided a copy of English Rows Eye Care’s Notice of Privacy Practices.
HIPAA Acknowledgement Date:*
HIPAA Acknowledgement Typed Name*
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Address & Phone Number

Returning Patient Information Form

Returning Patient Information Form

Step 1 of 5

Medical Insurance Information

Vision Insurance Information

Policy Holder Information

Patient Eye History

General Health

Pharmacy Information

Allergies

Contact Lenses / Glasses

Meaningful Use

Authorization

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