New Patient Registration Form

Welcome to Kapolei Eye Care

Please complete all portions of the form.
Patient Name*

First NameMiddle NameLast NameSuffix
Nickname
Preferred name (optional)
Date of Birth*

MonthDayYear
Date of Birth
Social Security #
Optional
Gender*

MaleFemaleOther
Marital Status*

SingleMarriedDivorcedWidowed
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number*

Area CodePhone Number
Home or Day Phone Number (optional)

Area CodePhone Number
Preferred Contact Number*

Cell PhoneHome or Day Phone
May We Contact You Through Email?*

YesNo
Email*
example@example.com
Name of Emergency Contact*

First NameLast Name
Relationship to Patient*

SpouseParentLegal GuardianSignificant OtherOther
Phone Number of Emergency Contact*

Area CodePhone Number
Primary Care Physician*
How did you hear about our office?*

Referred by PhysicianReferred by our patientInsurance WebsiteYelpGoogleTV CommercialOther
Demographics

*required by the US Census Bureau
Race (check all that apply)*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteDeclined To SpecifyOther
Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoDeclined to Specify
Preferred Language*

EnglishOther
Patient's Employer Information
Employment Status*

Employed Full-TimeEmployed Part-timeSelf-EmployedRetiredUnemployedHome-makerMinor
Employer*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Job Title/Position*
Responsible Party Information

If patient is under 18, this section MUST include parent/guardian information.
Person responsible for payment(s):*

Self *use information aboveSelf *different mailing address, fill out belowParentLegal GuardianOther *specify below
Relationship to Patient*
You selected Other, please specify here
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security #*
Used for electronic claims filing
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number*

Area CodePhone Number
Home or Day Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Insurance Information

On the day of your appointment, please give your insurance card(s) if applicable, to the receptionist to scan.
How many different insurances do you have?*

123NONE: I will be paying out of pocket for my exam(s).
Name of Primary Insurance*
Patient's Relationship To Subscriber:*

SelfSpouse/Significant OtherChild
Subscriber's Name*

First NameLast Name
Subscriber's Date of Birth*

MonthDayYear
Date of Birth
Subscriber ID#*
Name of Secondary Insurance*
Patient's Relationship To Subscriber:*

SelfSpouse/Significant OtherChild
Subscriber's Name*

First NameLast Name
Subscriber's Date of Birth*

MonthDayYear
Date of Birth
Subscriber ID#*
Name of Tertiary Insurance*
Patient's Relationship To Subscriber:*

SelfSpouse/Significant OtherChild
Subscriber's Name*

First NameLast Name
Subscriber's Date of Birth*

MonthDayYear
Date of Birth
Subscriber ID#*
Medical History Record
Height*
Ex: 6'0 Ft
Weight*
Ex: 130 lbs
Have you had any surgeries?*

NoYes
Please specify any surgeries here:*
Do you have any allergies?*

NoYes
Please specify here and include reaction:*
Do you take any Medications or Supplements?*

NoYes
Please list all Medications or Supplements here:*
Are you using any Over-The-Counter or Prescription eye drops?*

NoYes
Please list all eye drops you are using here:*
Eye Health History
When was your last full eye exam?*

12 months ago2 years ago3-4 years ago5-10 years agoThis is my first time doing a full eye exam
Have you been diagnosed with an eye diseases/conditions?*

Amblyopia (lazy eye)BlepharitisBlindnessCataract(s)Color BlindnessDiabetic RetinopathyDry Eye SyndromeEye InjuriesGlaucomaMacular DegenerationPosterior Vitreous DetachmentRetinal DetachmentStrabismus (eye turn)NONEOther
Have you had any eye operations?*

NoYes
Please list any eye operation history here:*
Ex: Cataract Surgery 2014 (both eyes)
Have you had any eye injuries?*

NoYes
Please list any eye injury history here:*
Ex: trauma to right eye 2016
Review of Systems
Do you have problems with any of these systems? Check all that apply.*

Fever, weight loss or gainEar, Nose, Throat, MouthCardiovascular (heart, hypertension, etc.)Respiratory (asthma, emphysema, etc.)GastrointestinalGenital, Kidney, BladderMuscles, Bones, Joints (arthritis, etc.)Skin (rash, itching, skin cancer, etc.)Neurological (Alzheimer's Disease, epilepsy/seizures, bell's palsy, etc.)Psychiatric (anxiety, depression, etc.)Endocrine (diabetes, hypothyroid, etc.)Blood/Lymph (anemia, cholesterol, etc.)Allergic/Immunologic (allergies, lupus, etc.)PregnantNursingNONE
Family History

Do you have any family members with the following conditions? Please use the dropdown box where applicable.

Eye Diseases/Conditions:

	Relationship to Patient
Amblyopia (Lazy Eye)
Blindness
Cataract(s)
Color Blindness
Eye Tumors
Glaucoma
Glaucoma Suspect
Macular Degeneration
Retinal Detachment
Strabismus (Eye Turn)
Other Eye Conditions

Systemic Diseases:

	Relationship to Patient
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Lupus
Stroke
Thryoid Disease

Social History
Do you drink alcohol?*

NoOccasional1 per day2-3 per day4+ per day
Do you smoke tobacco?*

NoOccasional1/2 pack per day1 pack per day1+ pack per dayE-Cig
Do you use illegal drugs?*

NoYes
Have you been diagnosed with diabetes/pre-diabetes?*

YesNo
If last blood sugar count is known, please provide: Blood Sugar Count
If last HA1c is known, please provide:A1c Level (ex: 6.2)
Your Appointment
What brings you in today? Please be specific as possible*
What kind of corrective lenses do you CURRENTLY wear:*

Glasses (to help see far)Glasses (to help see near)Glasses BiFocals (to help see far & near WITH LINE)Glasses TriFocals (to help see far, intermediate & near WITH 2 LINES)Glasses Progressive (to help see far, intermediate & near WITHOUT LINES)Soft Contact LensesRGP Lenses (Rigid Gas Permeable)CRT Lenses (Corneal Refractive Therapy)Scleral LensesOther
If you wear contact lens, how often do you replace them?*

DailyBi-weekly (every 2 weeks)MonthlyQuarterly (every 3-4 months)Other
COVID-19 Questionnaire
Have you had any flu like symptoms within the past 10 days? Check all that apply.*

FeverSore ThroatCoughDiarrheaEye InfectionChillsRunny NoseBody AchesRespiratory/Breathing IssueLoss of Taste and/or SmellNONE
Have you been tested for COVID-19?*

NoYes
When did you get tested?*

MonthDayYear
What was your result?*

PositiveNegative
Have you or any member of your household been in close contact with anyone that has tested POSITIVE for COVID-19?*

NoYes
Have you been tested for COVID-19?*

NoYes
When did you get tested?*

MonthDayYear
What was your result?*

PositiveNegative
Kapolei Eye Care HIPAA Authorization for Use or Disclosure of Health Care Information
PLEASE READ CAREFULLY

By signing this form, I authorize the use and disclosure of health information as described below:
- Description of Information: Submission of health and personal information to all insurance companies involved in the payment of the office visit or any other entity responsible for the payment of the visit.
- Name or class of person(s) authorized to make the used or disclosure: Any office employee directly involved in the care or claim submission to the insurance companies.
- Date or event when authorization expires: Indefinite from the date of this signed document.
- Description of each purpose of the requested use or disclosure: Obtain payment from the insurance companies, pre-authorization and post-authorization reviews.
WE WILL NOT RELEASE YOUR PERSONAL HEALTH INFORMATION TO ANYONE WITHOUT YOUR CONSENT. Please write the FULL NAME AND STATE RELATIONSHIP TO YOU of anyone you would like to authorize release of your Personal Health Information to below:
Ex: John Smith - Spouse
I understand that I have the right to revoke this authorization, in writing at any time, except (1) where uses or disclosures have already been made based upon my original permission, or (2) the authorization was obtained as a condition in securing insurance coverage and the insurer by law has the right to contest a claim or the insurance policy. I understand that the use and disclosures already made based upon my original permission cannot be taken back. To revoke the authorization, I must do so in writing and send it to: Nancy Chen, M.D., dba Kapolei Eye Care, at P.O. Box 75625, Kapolei, HI 96707.

I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and no longer protected by the Federal Privacy Standards. I may receive a copy of the full HIPAA disclosure for review upon my request.
Signature of Patient or Legal Representation*

Clear
If patient is a minor, unable to sign or without decision making capacity, relationship of person authorized to consent must be stated.
Name of Legal Representative

First NameLast Name
Relationship to Patient

ParentLegal GuardianPower of Attorney (Please provide copy of POA at appointment)Other
Pupil Dilation Consent
Dilation drops are used to dilate or enlarge the pupils of the eye to allow your Optometrist/Ophthalmologist a better view of the inside of your eye. You will only be dilated if your doctor finds it necessary for further treatment. You have the right to refuse dilation, but it is required for certain tests and to complete full eye exams.

Dilation of the pupils will cause temporary blurry vision and some light sensitivity. It is not possible for your doctor to predict how much your vision will be affected. Therefore, we advise caution in operating any equipment or machinery, including driving, until the effects of the drops have worn off. Adverse reactions, such as acute angle-closure glaucoma, may be triggered from the dilating drops. This is extremely rare and treatable with immediate medical attention.

I authorize dilation drops to be used from this day forward in the treatment
and management of my eye health.

Date or event when authorization expires: Indefinite from the date of this signed document.
Signature of Patient or Legal Representation*

Clear
If patient is a minor, unable to sign or without decision making capacity, relationship of person authorized to consent must be stated.
Name of Legal Representative

First NameLast Name
Relationship to Patient

ParentLegal GuardianPower of Attorney (Please provide copy of POA at appointment)Other
Account Holder Financial Responsibility

PLEASE READ CAREFULLY AND INITIAL IN EACH BOX*

	Initial of Patient or Legal Representative
1. I understand that I will be responsible for all known patient portions and non-covered services on the day of my visit. I understand that the collected amount is an ESTIMATE ONLY and that the correct amount will not be known until you bill my insurance. Any other charges that I am responsible for will be mailed to me after my insurance pays, or collected from me upon my next visit.
2. I understand that if I am covered under HMSA QUEST, Medicaid or AlohaCare it is my responsibility to make sure that I did not use my benefits for an eye exam and glasses for that year. If my benefits have been exceeded, I understand that I will be responsible for the whole amount due.
3. I understand that Kapolei Eye Care will make an effort to verify eligibility with my insurance plan(s), but ultimately, it is my responsibility to know the benefits of my own plan(s).
4. I understand that if I am part of a Union (ex: Carpenters, Painters, etc.) payment(s) will be collected in full from me for all services, where for exam or appliances and will be reimbursed accordingly. It will be my responsibility to verify that I am eligible for any type of appliances for that year. (Union insurances are not allows to disclose that information to providers, only to members).
5. I understand that it is my responsibility to inform Kapolei Eye Care of any insurance change(s) throughout the year. If no updates are received from me on a timely manner, I understand that my insurance may reject/deny my claim(s) due to “timely filing deadline exceeded” and that I will be responsible for the whole amount owed.
6. I understand that there are non-covered services and taxes that my insurance may not cover at all and payment for these services are my responsibility. (ex: Refraction: determination of the power of my eyes to correct my vision with glasses or contact lenses, and Contact Lens Fitting: the fitting of contacts over the cornea, by determining the base curve, shape and diameters, etc). These procedures are not covered by Medicare and many other insurance plans. Charges determined by my insurance to be my responsibility thereafter will be billed to me.
7. I understand that it is my responsibility to pay for the deductibles and patient portions on the day of the services. I understand that Kapolei Eye Care is unable to accept payment plans except on emergency cases. Self-pay patients paying for services in full today may receive a discount off the visit, which must be paid in whole. Kapolei Eye Care accepts VISA, MasterCard, debit cards, money orders, personal check, and CareCredit. There will be a $25 service charge for all returned checks. In the event of default, I promise to pay legal interest (35%) on the debts, together with such collection costs and reasonable attorney fees as may be required to affect collection of this note.

While the filing of insurance claims is a courtesy that we extend to our patients, some charges such as deductible and copayments are your responsibility. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we ask that you contact us promptly for assistance with the management of your account.

AUTHORIZATION
I certify that the information I have provided to Kapolei Eye Care is true and correct. I acknowledge that I’ve read the above information. Further, I understand that I am responsible for payment of all charges for services and items provided. I understand that this is an open-ended agreement.

I authorize release of any information from my files including, but not limited to, my medical and financial records necessary to process my insurance claim(s) and request payment of insurance benefits to either myself or the part who accepts assignment/participation with my insurance company.
Signature of Patient or Legal Representation*

Clear
If patient is a minor, unable to sign or without decision making capacity, relationship of person authorized to consent must be stated.
Name of Legal Representative

First NameLast Name
Relationship to Patient

ParentLegal GuardianPower of Attorney (Please provide copy of POA at appointment)Other
On the day of your appointment, please provide your picture ID and insurance cards (if applicable) to scan. Thank you.
Should be Empty:

Welcome to Kapolei Eye Care

Demographics

Patient's Employer Information

Responsible Party Information

Insurance Information

Medical History Record

Eye Health History

Review of Systems

Family History

Social History

Your Appointment

COVID-19 Questionnaire

Kapolei Eye Care HIPAA Authorization for Use or Disclosure of Health Care Information

Pupil Dilation Consent

Account Holder Financial Responsibility