PATIENT REGISTRATION FORM
 
*Primary Care Physician Phone #
Referred By Phone #
How did you hear about our practice ?
PATIENT INFORMATION
* Required fields.
** Please enter only the last 4 digits of Social Security Number.
*Patient Name SSN *Date of Birth *Gender M F
*Address Apt# *City, State, Zip
*Home Phone# *Cell / Work Phone# Email
*Race African American Hispanic or Latino American Indian Asian Native Hawaiian/Pacific Islander White
*Preferred Language  
*Marital Status S M D W   Employer *Occupation
Employer's Address City, State, Zip
 
(If patient is a minor (Under 18 or full time student)
Guarantor SSN Birthdate Gender M F
Guarantor Address City, State, Zip
 
(If different from patient)
*Emergency Contact *Phone# *Relationship to patient
Spouse Name
 
INSURANCE INFORMATION
*Primary Insurance *Policy# Group#
Address City, State, Zip
*Insured Name *Date of Birth
*Phone# *Relationship to patient
 
Secondary Insurance Policy# Group#
Address City, State, Zip
Insured Name Birthdate
Phone# Relationship to patient
Do you have a vision policy? Name Insured Policy#
Phone#
 
I certify that the above information is correct and hereby authorize the release of medical information to my insurance company and/or to my referring physician. I assign to the physician(s) all payments for services rendered to my dependents or me. A copy of this authorization may be used in place of original. Insurance will be filed if the physician(s) are covered under my plan. It is my responsibility to obtain a referral if required. I understand that I will be responsible for all non-covered service, co-payments and deductibles. I hereby voluntarily consent to treatment at his/her office and authorize such treatments, examinations, medications. Co Payment is due at time of service.

 
*Enter Your Name Date
 
* Required fields.
*We are happy to submit a claim to (your insurance provider):
for services rendered. However, in most cases:
 
does not cover any services which is not approved, arranged or provided by your Primary Care Physician. (Please consult your Member Handbook for a list of services which do not require a referral form from your Primary Care Physician).
 
Your signature below indicates that if you receive specialty care services without the consent of your Primary Care Physician, you will assume financial responsibility for such services.
 
 
* Required fields.
*CHIEF COMPLAINT:
*HISTORY OF ANY ILLNESS, IF ANY:
*ARE YOU DIABETIC:
IF YES: ARE YOU INSULIN DEPENDENT:
IF SO HOW LONG?
WHAT TYPE?
HOW LONG?
DO YOU KNOW YOUR A1C?
WITHIN THE LAST 3 MONTHS?
*ALLERGIES (TO MEDICATIONS):
*MEDICATIONS:
*SURGICAL INFORMATION & DATES:
 
SOCIAL HISTORY
*DO YOU SMOKE
IF YES, FOR HOW MANY YEARS?
IF YOU QUIT, HOW LONG AGO?
*DO YOU DRINK ALCOHOL
IF YES, HOW OFTEN PER WEEK
 
FAMILY HISTORY: YOUR BLOOD RELATIVES ONLY
*AMBLYOPIA (LAZY EYE)
*BLINDNESS
*CATARACT
*CROSSED EYES
*DIABETIC RETINOPATHY
*GLAUCOMA
*MACULAR DEGENERATION
*RETINAL DETACHMENT
*CANCER
*DIABETES
*HEART DISEASE
*HIGH BLOOD PRESSURE
*STROKE
 
* Required fields.
CONTACT LENS INFORMATION
*Do you currently wear contacts:
In order to better serve you, please write in your current prescription or please bring it with you for your appointment.


If so, what is your current prescription:
Brand
Power
Base curve
Diameter
Right
Left
 
Have you ever ordered your contacts through us:
Have you experienced problems with your contacts in the past, and if so what type of
problems did you experience:
 
I understand that my Medical Insurance does not cover Contact Lens Evaluation Fees or any additional fees concerning my contact lens examination. I am also aware that it is my responsibility to pay the evaluation fee on the day services are rendered. Evaluation fees are priced between $100.00 & $150.00 depending on the type of contacts I am fitted for. All multi-focal contact evaluations are $200.00. Any patient requesting an updated contact prescription is subject to a $45.00 contact lens evaluation fee. Trial lenses are given at evaluation fee exams and if they become lost or ripped, a $10.00 restocking fee may also apply.
 
I understand that my Medical Insurance does not cover any portion of the price of contacts ordered and once the 1st initial order is placed and received by The Goodman Eye Center it is my responsibility to make full payment up front on the day of pick-up.
 
I understand that if I have either Eye Med Vision Plan or Davis Vision that covers any or all of the contact lens fitting, examination, or otherwise I will be responsible for payment in full on the day services are rendered. As a new patient of the Goodman Eye Center we will gladly set up an account for you so you can refill your contact lens prescription on line the easy way!
 
As a new patient of Goodman Eye Medical & Surgical Center we will gladly set up an account for you so you can refill your contact lens prescription on line the easy way!
 
 
 

Notice of Privacy Practices for Protected Health Information

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

With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care options. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment and applying for future care or treatment. It also includes billing documents for those services.

Example of uses of your health information for treatment purposes:
A nurse obtains treatment information about you and records it in a health record. During the course of your treatment, the doctor determines a need to consult with another specialist in the area. The doctor will share the information with such specialist and obtain input.

Example of use of your health information for payment purposes:
We submit a request for payment to your health insurance company. The health insurance company requests information from us regarding medical care given. We will provide information to them about you and the care given.

Example of Use of Your Information for Health Care Operations:
We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.

Your Health Information Rights
The health record we maintain and billing records are the physical property of the practice. The information in it, however, belongs to you. You have a right to:

  • Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office. We are not required to grant the request but we will comply with any request granted;
  • Request that you be allowed to inspect and copy your health record and billing record--you may exercise this right by delivering the request in writing to our office;
    Appeal a denial of access to your protected health information except in certain circumstances;
  • Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office;
  • File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information;
  • Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office. An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care;
  • Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office; and Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.

If you want to exercise any of the above rights. Please contact Goodman Eye Medical & Surgical Center, 145 West Street , Milford, MA 01757, Telephone: 508-381-5600, in person or in writing, during normal business hours. We will provide you with assistance on the steps to take to exercise your rights.

Our Responsibilities

The practice is required to:
Maintain the privacy of your health information as required by law;

Provide you with a notice of your duties and privacy practices as to the information we collect and maintain about you;

Abide by the terms of the Notice;

Notify you if we cannot accommodate a requested restriction or request; and Accommodate your reasonable requests regarding methods to communicate health information with you.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our "Notice" or by visiting our office and picking up a copy.

To request Information or File a Complaint

If you have any questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Goodman Eye Medical & Surgical Center, at 508-381-5600. Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to Goodman Eye Medical & Surgical Center, You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services.

We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the practice. We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.

Other Disclosures and Uses

Notification
Unless you object, we may use or disclose your protected health information to notify, or assist in notifying a family member, personal representative, or other person responsible for your care, about your location and about your general condition, or your death.

Communication with Family
Using your best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or in payment for such care if you do not object or in an emergency.

Food and Drug Administration (FDA)
We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects, or post-marketing surveillance information to enable product recalls, repairs or replacements.

Workers Compensation
If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Public Health
As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Abuse & Neglect
We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.

Correctional Institutions
If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your protected health information necessary for your health and the health/safety of other individuals.

Law Enforcement
We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.

Health Oversight
Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.

Judicial/ Administrative Proceedings
We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order.

Disaster Relief
We may use and disclose your protected health information to assist in disaster relief efforts

Funeral Directors / Coroners
We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.

Organ Procurement Organizations
Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or other entitles engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Marketing
We may contact you to provide you with information about treatment alternatives, or with information about other health-related benefits and services that may be of interest to you.

For Specialized Governmental Functions
We may disclose your protected health information for specialized government functions as authorized by law, such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

Other Uses
Other Uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.

Website
If we maintain a website that provides information about our entity, this Notice will be on the website.
For Office Use Only
 
We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because:
 
Individual refused
 
Communication barriers prohibited obtaining the acknowledgment
 
An emergency situation prevented us from obtaining acknowledgment
 
Other (please specify):
 
* Required fields.
AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION
(Complies with the Health Insurance Portability and Accountability Act (HIPPA) of 1996. Implementing regulations at 45CFR 164.508 paragraph (c) ).
 
Completion of this document authorizes the disclosure and / or use of individually identifiable health information, as set forth below, consistent with Massachusetts Federal law concerning the privacy of such information.
 
USE AND DISCLOSURE OF HEALTH INFORMATION
 
I hereby authorize the use or disclosure of health information as follows:
*Persons / Organizations authorized to disclose the information:
 
Please deliver the records to me in care of the following Persons / Organizations authorized to receive the information:
Goodman Eye Center
145 West Street
Milford, MA 01757
(508) 381-5600, Fax: 508) 381-5610
The authorization applies to the following information:
 
COPIES OF THE ENTIRE patient record, including but not limited to registration and history forms completed by the patient; any medical history; mental or physical condition; treatment received; notes and observations; records of examination or treatment received from other practitioners; reports of diagnostic services and tests; correspondence; any other records used to make decisions about the patient prescription records, and all billing, payments, insurance, utilization and authorization records. Purpose: This disclosure is at the request of the individual patient or authorized representation as set forth below.
 
NOTICE OF RIGHTS AND OTHER INFORMATION
I am aware that I may revoke this authorization at any time. My revocation must be in writing, signed by me or on my behalf, and delivered to the persons / organizations authorized to disclose information as specified above. My revocation will be effective upon receipt, but will not be effective to the extent that the requestor or others have acted in reliance upon this authorization. I am aware that the information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected.
 
If signed by someone other than the patient, state relationship to the patient and authority to act on patient's behalf: