Annual Consent Form

Patient Annual Consent Form

Welcome to Northwoods Family Eyecare!
Thank you for you for choosing our office to provide you with your comprehensive eye examination and all your eyecare needs. Please fill out the following information in preparation for your upcoming appointment.
Have you been here within the last three years?*

YesNo

AGREEMENT TO RECEIVE TEXT MESSAGING COMMUNICATION
Our office utilizes electronic notification system (email, text messaging) to notify our patients of appointment reminders, glasses and contact lenses pick up, office closures, scheduling conflict, etc. This is the most effective and efficient way to notify our patients. By providing us with your cell phone number, you are giving us permission to communicate with you through text messaging. There is some level of risk that third parties might be able to read unencrypted text messages and it is your responsibility to provide Northwoods Family Eyecare with any updates to your cell phone number. Text messaging rates may apply.
I would like to receive (Please check ALL that apply):

Appointment Reminders/Recall VisitsInformation Regarding General Office Updates/Hours/Closures/Patient SatisfactionGlasses and/or Contact Lenses Pick-Up NotificationsDecline all

VERBAL CONSENT TO DISCUSS PROTECTED HEALTH INFORMATION
Because of HIPAA laws, we need permission to discuss your health and payment information with anyone other than yourself. If you want us to disclose this information verbally to anyone such as a spouse, child, parent, or friend, please click below:

I give permission to Northwoods Family Eyecare to VERBALLY discuss all vision and medical information with the following individuals, as well as discuss with them any other information pertaining to my account.I do not want to authorize anyone to access my account
I understand that I may cancel this permission at any time by writing to Northwoods Family Eyecare, but that cancelling will not affect any information that has already been released. This authorization will remain in effect until Northwoods Family Eyecare receives written notice to cancel it.
Individual 1
First and Last Name
Relationship 1
mother, child, spouse, sibling, friend
Individual 2
Relationship 2
mother, child, spouse, sibling, friend
Individual 3
Relationship 3
mother, child, spouse, sibling, friend

FINANCIAL AGREEMENT AND OFFICE POLICIES
I agree to assume all financial and personal responsibilities, as noted in the “Northwoods Family Eyecare Responsibilities and Consent below.
If patient is a minor, guarantor (person who will be financially responsible for account) will default to parent/legal guardian accompanying patient on day of exam.

NOTICE OF PRIVACY PRACTICES
I have been presented and understand the “Notice of Privacy Practices” of Northwoods Family Eyecare in the document below.

SIGNATURE
On the day of your exam, you will be asked for your insurance cards and a picture ID to help us prevent insurance fraud.

We can't wait to SEE you!
Signature*

Clear
Print Name (and relation if guardian)
Date

MonthDayYear
Date
Should be Empty:

Patient Annual Consent Form