STLZ01 Patient Registration Packet

Welcome to the St Lucie Eye Family!

Thank you for entrusting us with your eye care, we look forward to meeting you!

Before arriving for your appointment, please review and complete the following:

New Patient Information
Medical History
Insurance Authorization
Financial Policy
No-Show Policy
HIPPA Privacy Form
Additionally, please bring current Eyeglasses, Photo ID, and Insurance Cards to your appointment.

You should allow about 2 hours for your initial visit, which will include pupil dilation. Dilation drops frequently blur vision for up to 6 hours. You may experience sensitivity to light and difficulty driving or reading as the drops wear off. Bring sunglasses to protect your eyes and consider having a driver if you are particularly sensitive.

We understand that situations may arise that interfere with your scheduled appointment time. We are happy to help you reschedule when needed. If canceling or rescheduling your appointment, kindly give at least 24 hours notice. Failure to do so may result in a $25 charge.

Should you have any questions about your appointment or our services, please call our office at (772) 461-2020. We look forward to seeing you soon!

**Special Precautions
At this time, we no longer require masks for patients or staff. If you prefer staff wear a mask during your examination, please notify the front desk and we will be happy to accommodate your request.

NEW PATIENT INFORMATION

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

Age

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Home Phone Number

Please enter a valid phone number.

Work Phone Number

Please enter a valid phone number.

Cell Phone Number

Please enter a valid phone number.

Email

example@example.com

Employer

Occupation

Marital Status

Single

Married

Widowed

Divorced

Gender

Male

Female

Name of Spouse

First Name

Last Name

Emergency Contact

First Name

Last Name

Emergency Contact Phone Number

Please enter a valid phone number.

Referring Physician

Primary Care Physician

Pharmacy/Location

Primary Language Spoken

How did you hear about us?

Neighbor/Friend

Internet Search

Publication/Directory

Website

Physician

Other

Please Complete if Under 18 Years of Age or a Student

Father's Name

First Name

Last Name

Employer

Mother's Name

First Name

Last Name

Employer

MEDICAL HISTORY AND INTAKE FORM

REASON for visit. Briefly explain any current eye problems.

Do You Wear Glasses?

Yes

No

Number of years

Do You Wear Contacts?

Yes

No

Number of years

Please answer the following questions about your Medical Status and History:

Have you ever been treated for any medical conditions (e.g., diabetes, high blood pressure, arthritis, etc.)?

Yes

No

If YES, Please explain:

Have you ever had any surgery?

Yes

No

If YES, Please explain:

Have you ever been hospitalized?

Yes

No

If YES, Please explain:

Do you take any medications?

Yes

No

If YES, please list:

Do you have any food or drug allergies?

Yes

No

If YES, please list:

Have you or any of your family members been diagnosed with any of the following eye diseases?

Glaucoma

Cataract

Diabetes

Macular Degeneration

Blindness

Have you ever smoked?

Yes

No

If yes,

Current

Former

Do you drink alcohol?

Yes

No

Any recent changes in employment conditions?

Yes

No

If YES, Please explain:

Are you employed?

Yes

No

If YES, How many hours per week:

Review of Systems: Please check if you have any of the following conditions with a brief explanation.

	Yes	No	Brief Explanation
ALLERGY/ IMMUNOLOGY: Hives, Autoimmune Disease, Rheumatoid Arthritis
CARDIOVASCULAR: Chest Pain, Irregular Heartbeat, Heart Disease, A-Fib
CONSTITUTIONAL: Chronic fever, Unexpected Weight Loss/Gain, Fatigue
ENDOCRINE: Excess Thirst, Excess Urination, High Blood Sugar
GASTROINTESTINAL: Heartburn, Abdominal Pain, Diarrhea, Vomiting
GENITOURINARY: Pain or Discomfort, Blood in Urine
HEMATOLOGY/ONCOLOGY: Bruising, Prolonged Bleeding
HENT: Hearing Loss, Sinus, Sore Throat
INTEGUMENTARY: Skin Rashes, Excessive Dryness
MUSCULOSKELETAL: Muscle Aches, Joint Pain, Swollen Joints
NEUROLOGICAL: Numbness, Weakness, Headaches, Paralysis
PSYCHIATRIC: Depression, Anxiety
RESPIRATORY: Shortness of Breath, Wheezing, Coughing

PATIENT FINANCIAL RESPONSIBILITY
INSURANCE ASSIGNMENT AUTHORIZATION

I understand that I am financially responsible for all co-pays, deductibles, and charges not covered by insurance*. I agree to pay for these charges in full at the time of service unless other arrangements have been made in advance with St Lucie Eye.

I authorize the release of medical information to third-party payers in order to process claims for payment. I authorize payment directly to St Lucie Eye for services rendered. This authorization is effective immediately.

The insurance information I have provided is current and accurate.

*Non-covered services may include but are not limited to: contact lens exams, glasses, aesthetic items, medications including eye drops, and refraction testing.

Refraction is a non-covered service under Medicare and most medical insurance companies. The $40 refraction fee is charged to the patient once per year.
Contact lens exams, including prescription changes are also non-covered services.

I have read the Patient Financial Responsibility and Insurance Authorization and understand that I am financially responsible for non-covered services, insurance co-pays, and deductibles.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Patient Signature (Parent Signature if a Minor) *

Subscriber Signature (If Different fromPatient)

Date

HIPAA NOTICE OF PRIVACY POLICY

Protected Health Information (PHI) is personal and sensitive information related to an individual’s health care account. Disclosure of this information without patient consent is prohibited, except as permitted by law in the ongoing treatment, payment, and continuity of care of the patient.

I acknowledge that I am aware of the Privacy Practices (HIPAA) for St Lucie Eye.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Patient Signature (Parent Signature if a Minor) *

Date

HIPAA RIGHT OF ACCESS
AUTHORIZATION FOR ACCESS TO PROTECTED HEALTH INFORMATION

I hereby authorize the disclosure of my PROTECTED HEALTH INFORMATION (PHI) to the FOLLOWING INDIVIDUALS regarding my medical care. I understand that I may revoke this authorization at any time.

	Name	Relationship
1.
2.
3.

Name of Individual Giving this Authorization

First Name

Last Name

Date of BIrth

Date

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature of Individual Giving this Authorization *

Today's Date

Date

NO-SHOW APPOINTMENT POLICY

We understand that life happens, and your appointment plans may change.

Should you need to cancel or reschedule your appointment, please contact our office as soon as possible and no later than 24 hours before your scheduled time.

As a courtesy, we will make reminder calls for your appointments. If you have opted in to receive text or email reminders, please respond with the option to confirm or reschedule.

An established patient who misses a scheduled appointment
without canceling or rescheduling will be considered a No-Show and charged a $25.00 fee.
A second No-Show appointment is an additional $25.00.
A third No-Show appointment is $50.00.
No-Show fees are charged directly to the patient's account and
are due prior to the next visit.

If you should experience extenuating circumstances, please contact our office. You may contact St Lucie Eye 24 hours a day, 7 days a week at (772) 461-2020.

I have read and understand the No Show Policy and agree to its terms.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Patient Signature *

Date