New Patient - Minor

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Name* This field is required.
First Name
Last Name
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Date of Birth* This field is required.MM/DD/YYYY
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Gender* This field is required.
Male
Female
Other
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Home Address* This field is required.
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Email
example@example.com
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Phone Number* This field is required.
Please enter a valid phone number.
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Would you like to use CAPSULE PHARMACY?* This field is required.Capsule is an online pharmacy that provides FREE home delivery within 24 hours -You'll save money since Capsule auto-applies coupons -You'll save time since Capsule offers free delivery 7 days a week, whenever it's convenient to them. -You can manage your Rx's right from your phone. Email a pharmacist, set up refills, etc. -Capsule handles all of the insurance so it's less for you to worry about.
YESNO
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Pharmacy Name and Address
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Ok
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Primary Care Doctor's Name and Address
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Ok
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Emergency Contact Name
First Name
Last Name
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Emergency Contact Phone Number
Please enter a valid phone number.
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Are you or anyone in your household currently experiencing symptoms of COVID-19? * This field is required.These symptoms include fever, cough, shortness of breath, loss of taste or smell, chills, muscle pain, headache, or sore throat.
YESNO
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In the last 10 days, have you or anyone in your household tested positive for COVID-19?* This field is required.
YESNO
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Please reschedule to a later date when your PCR test is negative and you are symptom free.

Thank you
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Are you vaccinated fully for COVID-19? * This field is required.
YESNO
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What medical problems do you have?
None
Diabetes
High blood pressure
High cholesterol
Thyroid problems
Autoimmune disease
Bleeding disorder
Other
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What medications do you take?Please list name and dosage of each
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Past Ocular History (mark all that apply)
None
Glasses
Glaucoma
Dry Eye
Cataracts
Macular Degeneration
Other
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What eye drops are you taking?
None
Artificial Tears
Glaucoma medication
Other
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Does anyone in your family have eye problems?
None
Glaucoma
Cataracts
Glasses
Other
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Patient Consent for use and Disclosure of Protected Health Information* This field is required.I hereby authorize that payment from my medical insurance program or my Medicare benefits be made to the above named physician on any unpaid bills for services provided on or after today I also authorize any holder of medical or other information about me to release to their health care financing administration, its intermediaries, insurance companies, or their agents any information needed to determine benefits payable for services. I permit a copy of this authorization to be used in place of the original. I understand that I am financially responsible for any balance not covered by my insurance carrier NOTICE OF PRIVACY PRACTICES PATIENT ACKNOWLEDGEMENT I have received this practice’s Notice of Privacy Practices written in plain language The Notice provides in detail the uses and disclosure of my protected health information that may be made by this practice, my individual rights, how I may exercise these rights, and the practice’s legal duties with respect to my information I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information resident at, or controlled by, this practice I understand I can obtain this practice’s current Notice of Privacy Practices on Request. They are available to me at https://www.ocnyeye.net/privacy-practices.html . I hereby give my consent for Ophthalmic Consultant of New York to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Notice of Privacy Practices provides a more completed description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. Ophthalmic Consultant of New York PLLC reserves the right to revise its Notice of Privacy practices at any time. A revised Notice of Privacy Practices may be obtained by sending a written request to info@ocnyeye.com or by going to our website ocnyeye.com. With this consent, Ophthalmic Consultant of New York PLLC may call my home or other location and may leave a message on voicemail or answering machine or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and calls pertaining to my clinical care. With this consent, Ophthalmic Consultant of New York PLLC may mail to my home or other location any items that assist the practice in carrying out TPO, such as reminders, billing statements and medical information. With this consent, Ophthalmic Consultant of New York PLLC may email any items that assist the practice in carrying out TPO. By signing this form, I am consenting to Ophthalmic Consultant of New York PLLC to use and disclose my PHI (Protected Health Information) to carry out TPO (Treatment, operations). I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, the Ophthalmic Consultant of New York will not treat me.
I have read and agree to the terms
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Insurance Authorization and Consent* This field is required.MEDICARE PATIENTS: I request that payment by Medicare be made on my behalf to Ophthalmic Consultant of New York for services furnished to me by Ophthalmic Consultant of New York I authorize my medical information about me to be released to Medicare and its agents and information needed to determine payable benefits Ophthalmic Consultant of New York accepts the charge determination of the Medicare carrier as full payment I am responsible for deductibles, co-payments and non-covered services MEDIGAP PATIENTS and/or SECONDARY INSURANCE (AARP, BLUE SHIELD, EMPIRE, GHI, ETC): I understand that if! have secondary health insurance they will be billed after my primary insurance has paid. If Ophthalmic Consultant of New York do not participate with my secondary insurance I am responsible for any balance due as well as deductibles, co-payments and non-covered services OTHER INSURANCE (OXFORD, AETNA, ETC) Ophthalmic Consultant of New York maintains a list of health care service plans with whom they are contracted. If they are contracted with my plan, that insurance will be billed directly I am responsible for any deductible, copay or co-insurance for non-covered services at the time services are rendered NON-COVERED SERVICES: I understand that I am responsible for any non-covered services and accept full responsibility for all items and services if considered "not covered" by my insurance plan. THIS COULD INCLUDE BUT IS NOT LIMITED TO; REFRACTION, DIAGNOSTIC TESTING, TREATMENT AND OTHER SERVICES. RELEASE OF INFORMATION: Ophthalmic Consultant of New York may disclose all or any part of my medical record and/or financial record which is necessary or appropriate in order to bill my insurance company. A copy of this signed authorization may be used in place of the original. FINANCIAL AGREEMENT: I agree that in return for the services provided to the patient by Ophthalmic Consultant of New York, I will pay my account at the time services are rendered. If my account is sent to an attorney or collection agency, I agree to pay any expenses or attorney's fees, in addition to the past due account. I understand that if my account is delinquent, I may be charged interest at the legal rate. It is understood that the undersigned and/or patient is the primary responsible person for the bill regardless of insurance.
I have read and agree to the terms
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Health Insurance Portability and Accountability Act Consent* This field is required.Certain Waivers under HIPAA. (a) Patient acknowledges that neither Group nor Physician guarantees that communications with Physician using electronic mail ("e-mail"), facsimile, video chat, instant messaging, and cellular telephone are secure or confidential methods of communications. Accordingly, Patient expressly waives Group’s and Physician’s obligations under the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. § 1320d et seq.), as amended by the Health Information Technology for Economic and Clinical Health Act of 2009, and all rules and regulations promulgated thereunder (collectively, "HIPAA"), and other state and federal laws and regulations applicable to the use, maintenance, and disclosure of patient-related information, to guarantee confidentiality with respect to correspondence using such means of communication. Patient acknowledges that all such communications may become a part of Patient’s medical records maintained by Physician. (b) By providing Patient’s e-mail address to Physician, Patient authorizes Physician to communicate with Patient by e-mail regarding Patient’s "protected health information" ("PHI") (as defined under HIPAA) and Patient understands and agrees to the following: E-mail is not necessarily a secure medium for sending or receiving PHI and, accordingly, any third party may gain access to such PHI; Although Group and Physician will make all reasonable efforts to keep e-mail communications confidential and secure, neither Group nor Physician can assure or guarantee the absolute confidentiality of such e-mail communications. Patient acknowledges and agrees that Ophthalmic Consultant of New York, PLLC, (or OCNY for short), along with their assigns, will be entitled to use any data, discoveries, results, improvements or other information resulting from the Services for any lawful purpose whatsoever, including, but not limited to, internal research, academic or other publications or commercial purposes. All data will be kept on a Cloud Based system that is password protected, and accessible to OCNY staff. I give my express permission to OCNY, to obtain and access to all of my medical records. I understand that my personal and medical information may be stored on a password protected secure cloud service.
I have read and agree to the terms
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Cancellation / Missed appointment Fee - $25* This field is required.We understand that plans change and emergencies arise. Please notify us as soon as possible if you need to cancel or reschedule your appointment. OCNY has a 24-hour cancellation policy. This means that missed appointments or same-day cancellations or rescheduled appointments are subject to a $25.00 Cancellation Fee for office visits. These fees are applied whether or not you receive a reminder call or text from our office. They also apply to appointments made just one day in advance. Please help us service you better by keeping scheduled appointments.
I have read and agree to the terms
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Permission to Consent for Medical Care to Minor or Incapacitated Adult* This field is required.I grant OCNY the permission to perform an examination which may include dilation, contact lens fitting (including contact lens class and all subsequent follow-ups), vision therapy (VT follow-ups), diagnosis and/or treatment to be rendered to the patient on the advice of any doctor licensed to practice medicine to my child / incapacitated adult
I have read and agree to the terms
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Name of Parent or Guardian
First Name
Last Name
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Consent and Signature (scroll down to sign)* This field is required.The information filled in this from is true to my knowledge. I agree to the terms and conditions outlined in the previous pages. I authorize my insurance benefits to be paid directly to Ophthalmic Consultants of New York, PLLC. I understand that I am financially responsible for any balance. I also authorize Ophthalmic Consultants of New York or insurance company to release any information required to process my claim. Payment is expected at the time of the visit unless we participate with your insurance plan. Any Copayment required under your plan is due at the time of the visit. I have received the Notice of Privacy Practices and I have had an opportunity to review at https://www.ocnyeye.net/privacy-practices.html.
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Take Photo of Front of Insurance Card
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Take Photo of Back of Insurance Card
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Take Photo of Front of Driver's License
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Take Photo of Back of Driver's License
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Take Photo of COVID Vaccine Card
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