Today’s Date:

PATIENT INFORMATION

Patient’s Last Name: First: Middle: Nickname:

Social Security: Salutation: Sex:

Birth Date: Primary Language: Race: Ethnicity:

Address: [Address/ P.O Box, City, ST ZIP Code]

Home Phone No.: Cell Phone No.: Work Phone No.: (include extension)

Email: Marital Status:

Other family members seen here: [Other patients] RESPONSIBLE PARTY

Last Name: First: Middle: Birth Date: Sex:

Address: [Address/ P.O Box, City, ST ZIP Code]

Home Phone No.: Cell Phone No.: Work Phone No.: (include extension)

Email: Social Security:

Demographic Information Form

How did you hear about us?

Were you referred by your doctor? If so, please list the doctor's name

Emergency Contact

Name: Phone: Relationship:

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Primary Insurance Information

Today’s Date:

INSURED INFORMATION

Insured is: Carrier Insurance Name:

Last name: First Name: Middle Initial:

Birth Date: Relationship to Insured

Policy Number: Group Number:

Secondary Insurance Information (If applicable)

INSURED INFORMATION

Insured is: Carrier Insurance Name:

Last name: First Name: Middle Initial:

Birth Date: Relationship to Insured

Policy Number: Group Number:

Insurance Information Form

Responsible Party Signature Today's Date

The above information is true to the best of my knowledge. I authorize my insurance benefits to paid directly to Peak Vision Center. I understand that I am financially responsible for any balance. I also authorize Peak Vision Center or insurance company to release any information required to pay my claims.

Disclosure: Our patients have the right to know the financial interest or ownership in hospitals and/or facilities. Dr. Chang and Dr. Burden have ownership in Premier Surgery Center.

• I have received and signed the Financial Policy of Peak Vision Center• I have received and signed a copy of the Notice of Medical Information Privacy Rights for Peak Vision Center• If you have an account that is turned over to collections you will be responsible for your balance, attorney

fees, and collection fees.• I may be responsible for a refraction fee of 40.00 and I understand Medicare will not pay that fee.• I may be responsible for facility, anesthesia, and laboratory fees.• I understand there is a no show fee of 30.00

Health History FormPlease Fill Out Entire Form

Name: Date of Birth:

Primary Physician: Phone:Referring Provider:

Review of Symptoms: Check all that apply

Eyes:Blurry VisionBurning/DrynessDouble VisionExcess Tearing/Watering

Glare/Light Sensitivity

Itching/ScratchingLoss of VisionLoss of Side VisionPain or SorenessRedness Reading In General

Seeing at a Distance

Additional Concerns:

Eye History:CataractGlaucomaEye MuscleOther

Date Diagnosed Date SurgeryRetina ProblemEyelidRefractive

Date Diagnosed Date Surgery

Current Eye Medications:

Current Medications and Usage:

Over the Counter Medication:

Allergies to Medicines:

Height: Weight:

Surgical History (with dates):

Family History (Check those that Apply and Write the Relationship to you)Cataract Macular DegenerationGlaucomaBlindness Cancer DiabetesCardiovascular Disease StrokeOther Major Illness or Hereditary Disorder

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Constitutional SystemsFeverWeight Loss/Weight GainTrouble Sleeping/Insomnia

Medical History: Check all that apply

Cardiovascular

High Blood Pressure

Congestive Heart FailureHeart Attack/Coronary StentArrhythmia (AFib, tachy, etc)

Elevated CholesterolHistory of Bypass SurgeryPacemaker/ICD

Hearing Problems/TinnitusEars, Nose, Mouth, Throat

Respiratory

Sinus Congestion

EmphysemaAsthmaLung CancerSleep ApneaCOPDChronic Cough/BronchitisOxygen Use

Neurological

Multiple Sclerosis

Migraines/HeadachesSeizures/EpilepsyStroke

Parkinson’s DiseaseAlzheimer’s/DementiaVertigo

G.E.R.D/Acid Reflux

GastrointestinalHepatitisUlcers/BleedingStomach/Bowel Cancer

Overactive Bladder

GenitourinaryEnlarged Prostate/Prostate CancerCervical/Ovarian/Uterine CancerKidney Disease

Currently Pregnant

Bell’s Palsy

MusculoskeletalOsteopenia/OsteoporosisDegenerative (Osteo) ArthritisGout

Fibromyalgia

IntegumentaryShinglesSkin CancerEczema/Psoriasis

Lymphoma

Hematologic/LymphaticAnemia/Sickle CellHemophiliaLeukemia

Lyme Disease

Schizophrenia

PsychiatricDepression/BipolarAnxietyPTSD

Mentally Disabled

Hyperthyroidism

EndocrineType 1 Diabetes Type 2 DiabetesHypothyroidism

Breast Cancer

Lupus

Allergic/ImmunologicSeasonal Allergies/Hay FeverRheumatoid ArthritisSjogren’s (dry eye/mouth)

HIVOther Immune Disorder

Social HistoryAlcohol Everyday Occasional

None

Tobacco Heavy Light ChewNever

Drugs Marijuana OtherNone

Exercise Yes No

Latest Hgb/A1c

Explanation of Other Diagnosed Medical Condition Not Listed:

Date: Signature:

Former

SUMMARY NOTICE OF PRIVACY PRACTICES

THIS IS A SUMMARY OF OUR NOTICE OF PRIVACY PRACTICES, WHICH DESCRIBES HOW

MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU

CAN GET ACCESS TO THIS INFORMATION.

Our Notice of Privacy Practices provides information about how we may use and disclose protected health

information about you. The notice contains Patient rights section describing your rights under the law. You

have the right to review our Notice before signing this Consent. You may obtain a copy by asking the front

desk or Privacy Officer. The terms of our Notice may change. If we change our Notice, you may obtain a

revised copy.

Our pledge to protect your privacy:

Skyline Vision Clinic and Laser Center is committed to protecting the privacy of your medical

information. Your care and treatment is recorded in a medical record. So that we can best meet your medical needs, we share your medical record with the providers involved in your care. We share your

information only to the extent necessary to collect payment for the services we provide, to conduct our business operations, and to comply with the laws that govern health care. We will not use or disclose

your information for any other purpose without your permission.

Patient Rights - You have the following rights regarding your medical information: ▪ to request to inspect and obtain a copy of your medical records, subject to certain limited

exceptions; ▪ to request to add an addendum to or correct your medical record; ▪ to request an accounting of Skyline Vision Clinic and Laser Center disclosures of your medical

information; ▪ to request restrictions on certain uses or disclosures of your medical information; to request that

we communicate with you in a certain way or at a certain location; and to receive a copy of the

full version of our Notice of Privacy Practices.

We may use and disclose medical information about you for the following purposes:

▪ to provide you with medical treatment and services; ▪ to bill and receive payment for the treatment and services you receive; ▪ for functions necessary to run Skyline Vision Clinic and Laser Center and assure that our

Patients receive quality care; ▪ to provide basic contact information (no medical information is provided) to our development

office for purposes of fundraising for Skyline Vision Clinic and Laser Center; to support our

standing as a federally qualified health center; and as required or permitted by law.

ACKNOWLEDGEMENT OF RECEIPT

OF SUMMARY NOTICE OF PRIVACY PRACTICES

Revised May 17, 2018

By signing this form, you consent to our use and disclosure of protected health information about you for treatment,

payment and health care operations. You have the right to revoke the Consent in writing, signed by you. However,

such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. Skyline

Vision Clinic and Laser Center provides this form to comply with the Health Insurance Portability and

Accountability Act of 1996 (HIPAA).

_____________________________ ________________________________ __________

Name of Patient (print) Signature of Patient Date

_____________________________ ________________________________ __________ Signature of Patient Representative Relationship to Patient Date

(Required if Patient is a minor or an adult who is unable to sign this form)

I understand that my health care and the payment for my health care will not be affected if I do not sign this form

________ initials

Communication Preferences:

Home phone number: ___________________ Mobile phone number: __________________

In caring for our patients, it may be necessary for Skyline Vision Clinic and Laser Center staff to contact you by

phone. When we are not able to speak to you directly, we like to leave messages when possible. In order to protect

your privacy, it is Skyline Vision Clinic and Laser Center’s policy to not leave messages with anyone except the

patient or legal guardian, nor leave specific information on an answering machine/voicemail system unless we have

your written permission to do so.

Yes, I want you to leave a voice mail. (Please circle) Home Mobile

No, I do not want you to leave a voice mail.

Skyline Vision Clinic and Laser Center may disclose your medical information such as exams, labs/radiology

results, appointments and your insurance or billing information to the following people:

____________________________________________ ________________________________________

Name Relationship Phone Number Name Relationship Phone Number

____________________________________________ ________________________________________

Name Relationship Phone Number Name Relationship Phone Number

No, I do not want you to discuss my medical care with anyone other than me.

I request removal from lists that initiate promotional or marketing communications Yes: _______ initials