• Welcome to Kapolei Eye Care

    Due to the COVID-19 pandemic, we recommend that our patients complete this form prior to their appointment to reduce the amount of time spent in our office for their own health and safety and for our staff. If you are not comfortable filling out this form online, please call our office at (808) 674-2273 and a member of our staff will do a phone work-up instead. Mahalo for your cooperation.
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  • Demographics

    We are required by the US Census Bureau to ask for this information.


  • Patient's Employer Information

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  • Responsible Party Information

    If patient is under 18, this section MUST include parent/guardian information.
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  • Insurance Information

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  • Medical History Record

  • Eye Health History


  • Review of Systems

  • Family History

    Please use the drop down boxes for each disease to specify if a family member or NONE.
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  • Social History

  • Your Appointment



  • If you are diabetic/pre-diabetic, do you check your blood sugar at home?   *  If so, what was the count AND when was it done         

  • Do you know what was your last HA1c?   *   Please provide last A1c: and when was it taken?

  • COVID-19 Questionnaire

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  • Kapolei Eye Care HIPPA 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.
  • 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.
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  • If patient is a minor, unable to sign or without decision making capacity, relationship of person authorized to consent must be stated.


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


  • Account Holder Financial Responsibility

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


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