Information & Registration

Gender*
Male   Female    

Please provide Home Phone and Cell Phone numbers and Email address for our Appointment Reminder system

Text   Voice

Please select which is your preferred method of contact
Home Phone   Cell Phone   Email  

Marital Status    
Single
Married
Divorced
Widowed

Are you currently residing or being cared for by
Skilled Nursing facility
Inpatient Rehabilitation facility
Hospice

Preferred Language
English
Spanish
Chinese
French
Tagalog
Russian
Vietnamese

Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Ethnicity
Hispanic
Not Hispanic

May we speak with anyone other than yourself regarding financial statements, test results, or any other services provided by our office regarding your medical treatment?*
Yes
No

Were we recommended by a friend or family member?
Yes
No

Were you sent to us by a doctor who we need to update on your vision care?
Yes
No

Do you have Routine Vision or Health Insurance Coverage?
Yes
No

Person Responsible for Financial Statement (Complete if patient is under 18 or a student)

Authorization for Treatment While I am at the Kansas City Eye Clinic (hereinafter, The Eye Clinic*), I permit the employees, the healthcare provider and all other persons caring for me to treat me in ways they judge are beneficial to me. I understand the attending healthcare provider will explain to me the nature of my condition and his/her recommended treatment and any associated risk involved with that treatment. I also understand that they will explain to me the other ways my condition could be treated. I further understand that this care may include diagnostic testing, examinations, medical and/or surgical treatment and no guarantees have been made to me regarding the outcome of this care.

Medicare Lifetime Consent I certify that the information given by me in applying under the Title XVII of the Social Security Act is true and correct. I authorize any holder of my medical or other information to release this information to the Social Security Administration, its intermediaries or carriers as required to support a Medicare Claim for services provided by The Eye Clinic. I authorize The Eye Clinic to submit a claim for Medicare benefits payable on my behalf. I request that payment of authorized Medicare benefits be made directly to The Eye Clinic and/or its doctors on my behalf; I assign those benefits to The Eye Clinic and/or its doctors.

All Other Insurance Authorization is hereby granted to The Eye Clinic to release medical records and other requested information for the completion of claims to my insurance company. I further authorize payment for medical benefits to be made directly to The Eye Clinic. I understand that I am personally and financially responsible for all services provided by The Eye Clinic, unless covered by Workers’ Compensation.

*”The Eye Clinic” refers to the Kansas City Eye Clinic, its doctors and employees where appropriate.

Patient Signature (required) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.

 

This information has been prepared for your benefit and reference. It contains our policies regarding insurance plans, billing and payment for our services.

The Kansas City Eye clinic will file claims for primary and secondary insurance plans on your behalf. Co-payments, charges for non-covered services and deductibles are due in full at time of service.

It is your responsibility (and the guardian of minors’ responsibility) to be aware of and follow your insurance plan guidelines and restrictions. You are responsible for obtaining a referral if your plan requires one. You are responsible for selecting a provider that participates with your insurance. The most up-to-date and comprehensive list of participating providers is available when you speak directly with your insurance plan; the Kansas City Eye Clinic cannot provide as up-to-date a list. You must use the information provided by your insurance company to determine if your doctor is a participating provider.

The Kansas City Eye Clinic does NOT file claims to automobile or liability insurance. Payment for all charges is due at the time of service. The patient will be provided with the information they need to file their own claim to the insurance company.

Kansas City Eye Clinic will follow-up on unpaid insurance claims. However, your insurance coverage is an agreement between you and your insurance plan and it is your responsibility to assure that services are paid. If your insurance coverage changes, delays or denials as a result of insurance information that is incomplete or not up-to-date will result in the payment for services and materials due directly from the patient.

Adult or teenage children who require examination, treatment, eyeglasses or lenses must have required insurance information and be prepared to pay any balance or fee not covered by insurance.

Routine vision plans will not cover exams when the patient has a vision or eye complaint or a medical diagnosis. These plans are generally for healthy eye exams and cannot be billed for care when there is a complaint or a medical diagnosis.

Most insurance companies consider a REFRACTION to be a NON-COVERED service. A refraction is the test used to determine the power and prescription of your eyeglasses or contact lenses. You are responsible for payment of the refraction if your insurance does not cover it.

Your Social Security number is a required part of your financial information with the Kansas City Eye Clinic. This information, as with your medical record, is protected with strict confidentiality. When the Clinic does not receive full payment for all charges at the time of service, by definition, we extend credit to the patient, and consequently can appropriately ask for this information to be part of our records. Alternatively, all charges can be paid in full until insurance makes payment after which we will process a refund to the patient.

The Kansas City Eye Clinic will assess a charge for copies of medical records to cover the costs of processing the record. A patient will be provided 10 pages of their medical record at no charge. Additional or subsequent pages will be provided at 50 cents per page and a $10.00 processing fee per occurrence after appropriate authorizations have been made.

Your signature below indicates that you have read each of the requirements and advisories above, agree to and understand your obligations.

Patient or Financially Responsible Party Signature (required) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.

 

Medication Allergies?
Yes
No

Past Ocular History – please check all that apply

 

Ocular Surgeries – please check all that apply

 

Current Medications used on or for YOUR EYES (Please list)

Ocular Significant Illnesses – please check all that apply

 

Systemic Illnesses – please check all that apply

 

Do you have or are you being treated for Diabetes?
Type I
Type II

Infections – please check all that apply

 

General Surgeries / Operations - please list

Current Other Medications - please list

Please check if you have ever taken
Flomax (Tamsulosin)
Cardura (Doxazosin)
Minipress (Prazosin)
Hytrin (Terazosin)
Uroxatral (Alfuzosin)
Rapaflo (silodosin)

Family History – please check all that apply

 

Social History – please check all that apply

 

Smoking
Current every day smoker
Current some day smoker
Former smoker
Never smoked

Alcohol Use
Yes
No

Drug Use
Yes
No

Are your CURRENTLY EXPERIENCING any of the following - please check all that apply
 

The Kansas City Eye Clinic
 

This notice describes how medical information about you may be used and disclosed, and how you can gain access to this information. Please review it carefully.

Protected health information (PHI), about you, is maintained as a written and/or electronic record of your contacts or visits for healthcare services with our practice. Specifically, PHI is information about you, including demographic information (i.e., name, address, phone, etc.), that may identify you and relates to your past, present or future physical or mental health condition and related healthcare services.

Our practice is required to follow specific rules on maintaining the confidentiality of your PHI, using your information, and disclosing or sharing this information with other healthcare professionals involved in your care and treatment. This Notice describes your rights to access and control your PHI. It also describes how we follow applicable rules and use and disclose your PHI to provide your treatment , obtain payment for services you receive, manage our healthcare operations and for other purposes that are permitted or required by law.

Your Rights Under The Privacy Rule Following is a statement of your rights, under the Privacy Rule, in reference to your PHI. Please feel free to discuss any questions with our staff.

You have the right to receive, and we are required to provide you with, a copy of this Notice of Privacy Practices - We are required to follow the terms of this notice. We reserve the right to change the terms of our notice, at any time. Upon your request, we will provide you with a revised Notice of Privacy Practices if you call our office and request that a revised copy be sent to you in the mail or ask for one at the time of your next appointment. The Notice will also be posted in a conspicuous location within the practice, and if such is maintained by the practice, on it's web site.

You have the right to authorize other use and disclosure - This means you have the right to authorize any use or disclosure of PHI that is not specified within this notice. For example, we would need your written authorization to use or disclose your PHI for marketing purposes, for most uses or disclosures of psychotherapy notes, or if we intended to sell your PHI. You may revoke an authorization, at any time, in writing, except to the extent that your healthcare provider, or our practice has taken an action in reliance on the use or disclosure indicated in the authorization .

You have the right to request an alternative means of confidential communication - This means you have the right to ask us to contact you about medical matters using an alternative method (i.e., email, telephone), and to a destination (i.e., cell phone number, alternative address, etc.) designated by you. You must inform us in writing, using a form provided by our practice, how you wish to be contacted if other than the address/phone number that we have on file. We will follow all reasonable requests.

You have the right to inspect and copy your PHI - This means you may inspect and obtain a copy of your complete health record. If your health record is maintained electronically, you will also have the right to request a copy in electronic format We have the right to charge a reasonable fee for paper or electronic copies as established by professional, state, or federal guidelines.

You have the right to request a restriction of your PHI - This means you may ask us, in writing, not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. If we agree to the requested restriction, we will abide by it, except in emergency circumstances when the information is needed for your treatment. In certain cases, we may deny your request for a restriction. You will have the right to request, in writing, that we restrict communication to your hea[th plan regarding a specific treatment or service that you, or someone on your behalf, has paid for in full, out-of-pocket. We are not permitted to deny this specific type of requested restriction.

You may have the right to request an amendment to your protected health information - This means you may request an amendment of your PHI for as long as we maintain this information. In certain cases, we may deny your request.

You have the right to request a disclosure accountability - This means that you may request a listing of disclosures that we have made, of your PHI, to entities or persons outside of our office.

You have the right to receive a privacy breach notice - You have the right to receive written notification if the practice discovers a breach of your unsecured PHI, and determines through a risk assessment that notification is required.

If you have questions regarding your privacy rights, please feel free to contact our Privacy Manager. Contact information is provided on the following page under Privacy Complaints.

How We May Use or Disclose Protected Health Information
Following are examples of uses and disclosures of your protected health information that we are permitted to make. These examples are not meant to be exhaustive, but to describe possible types of uses and disclosures.

Treatment - We may use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party that is involved in your care and treatment. For example, we would disclose your PHI, as necessary, to a pharmacy that would fill your prescriptions. We will also disclose PHI to other Healthcare Providers who may be involved in your care and treatment.

Special Notices - We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment . We may contact you by phone or other means to provide results from exams or tests and to provide information that describes or recommends treatment alternatives regarding your care. Also, we may contact you to provide information about health-related benefits and services offered by our office, for fund-raising activities, or with respect to a group health plan, to disclose information to the health plan sponsor. You will have the right to opt out of such special notices, and each such notice will include instructions for opting out.

Payment - Your PHI will be used, as needed, to obtain payment for your healthcare services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the healthcare services we recommend for you such as, making a determination of eligibility or coverage for insurance benefits.

Healthcare Operations - We may use or disclose, as needed, your PHI in order to support the business activities of our practice. This includes, but is not limited to business planning and development, quality assessment and improvement, medical review, legal services, auditing functions and patient safety activities.

Health Information Organization - The practice may elect to use a health information organization, or other such organization to facilitate the electronic exchange of information for the purposes of treatment, payment, or healthcare operations.

To Others Involved in Your Healthcare - Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person, that you identify, your PHI that directly relates to that person's involvement in your healthcare. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, of your general condition or death. If you are not present or able to agree or object to the use or disclosure of the PHI, then your healthcare provider may, using professional judgment determine whether the disclosure is in your best interest. In this case, only the PHI that is necessary will be disclosed.

Other Permitted and Required Uses and Disclosures - We are also permitted to use or disclose your PHI without your written authorization for the following purposes: as required by law; for public health activities; health oversight activities; in cases of abuse or neglect; to comply with Food and Drug Administration requirements; research purposes; legal proceedings; law enforcement purposes; coroners; funeral directors; organ donation; criminal activity; military activity; national security; worker's compensation; when an inmate in a correctional facility; and if requested by the Department of Health and Human Services in order to investigate or determine our compliance with the requirements of the Privacy Rule.

Privacy Complaints
You have the right to complain to us, or directly to the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying the Privacy Manager at 913-341-3100 or 800-333-5371.

We will not retaliate against you for filing a complaint.

Effective Date 09/20/2013 – Publication Date 9/20/2013

By my signature below, I acknowledge that I have received Kansas City Eye Clinic’s Notice of Privacy Practices.

This acknowledgement page will be retained in the patient’s record. If acknowledgement is not obtained, the reasons are documented below.