New Patient Registration

1

Patient Name* This field is required.

First Name

Last Name

2

Driver's LicensePlease take a photo of your driver's license or legal ID. (Rest assured that documents are stored in a HIPAA secure manner.)

3

Insurance Card(s) FRONTPlease take a photo of the FRONT of ALL of your medical insurance card(s) - primary and secondary - and any others that you may have. Please note that we do NOT accept vision insurance.

4

Insurance Card(s) BACKPlease take a photo of the BACK of ALL of your medical insurance card(s) - primary and secondary - and any others that you may have. Please note that we do NOT accept vision insurance.

5

Date of Birth* This field is required.

6

Social Security Number* This field is required.REQUIRED for Medicaid, Tricare, Champ VA, and VA Community Care patients. All others may type "none" if you do not wish to provide.

7

Address* This field is required.

8

Phone Number* This field is required.

9

Do you consent to receive text messages?* This field is required.These messages may contain health related information and could be viewed by anyone who has access to your phone. You have the right to opt out anytime with written notice.

Yes

No

10

Email Address* This field is required.This is our primary method of communication. If you do not wish to provide an email address please type "none", but you may miss important notifications.

11

Do you consent to receive email messages?* This field is required.These messages may contain health related information that could be viewed by anyone who has access to your email. You have the right to opt out anytime with written notice.

Yes

No

12

Smoking Status* This field is required.

Never Smoked

Former Smoker

Current Smoker

13

Emergency Contact* This field is required.

14

Primary Care PhysicianPlease type "none" if you do not have a primary care doctor.

15

Have you seen Dr. Bhasin previously at another practice?* This field is required.

Yes. Please request your records from that practice to be faxed to 413-289-8828.

No

16

How did you hear about us?* This field is required.Select all that apply.

My doctor. (Please request for your records to be faxed to our office at 413-289-8828 prior to your appointment.)

My friend/family

Google

Facebook

Insurance Directory

Other

17

Preferred Pharmacy* This field is required.

18

Primary MEDICAL Insurance* This field is required.We do not accept vision insurance.

19

Secondary MEDICAL Insurance* This field is required.We do not accept vision insurance.

20

Previous Eye Surgeries or Injuries* This field is required.

21

Current Eye Drops* This field is required.

22

Current Medical Conditions (Diabetes, High Blood pressure, etc)* This field is required.

23

Family history of eye conditions* This field is required.

24

Are you allergic to any medications?* This field is required.

25

Current Medications* This field is required.

26

Do you use corrective eyewear? (Select all that apply.)* This field is required.

Glasses (Bring your glasses to your appt.)

Contacts (Stay out of contacts 3 days prior to your appt.)

None

27

Would you like a refraction (Glasses Prescription)?* This field is required.

Yes. I understand that this service is not covered by MEDICAL insurance. The cost is $54 when paid at the time of service (original price = $108). We do NOT participate with VISION insurance.

No. I will not receive a glasses prescription.

28

Contact Lens Rx: Dr. Bhasin does NOT perform contact lens fittings.* This field is required.

I understand that Dr. Bhasin does NOT provide contact lens prescriptions.

29

Dilation Policy: Dilation allows Dr. Bhasin to view the back of your eyes. All patients are dilated at the first visit and as needed thereafter. Your eyes will be sensitive to light and your near vision will be blurred for 3-4 hours. Please bring a driver and sunglasses to your appointment.* This field is required.

I have read, understood, and agree to the dilation policy. I will notify my technician if I prefer not to be dilated.

30

Sick Policy: Out of consideration for our staff and other patients, please reschedule your appointment if you are not feeling well. If you think you have pink eye (or any contagious eye condition), please inform our front desk so we can provide a separate waiting area for you.* This field is required.

I have read, understood, and agree to the sick policy and will notify a technician if I need a separate waiting room.

31

No Show policy: A $50 no- show fee will be incurred by patients who do not show up for their scheduled appointments and fail to notify the office to reschedule.* This field is required.

32

Cancellation Policy: We kindly request that you notify us at least 1 business day in advance of your appointment. If you cancel or reschedule on the same day or fail to arrive for your appointment (later than 30 minutes), you will be marked as a “NO SHOW”. Two consecutive or greater than 50% NO SHOWS will result in termination from the practice.* This field is required.

I have read, understood, and agree to the cancellation policy.

33

Insurance Policy: Please contact your MEDICAL insurance company PRIOR to your visit to understand your benefits. If your insurance company denies payment, or we do not receive payment 60 days from filing your claim, the amount will then become due and payable by you. Remember that your coverage is a contract between you and your insurance company. Although we will make a good faith effort to assist you in obtaining your benefits, we cannot force your insurance company to pay for the services we have provided to you.* This field is required.

I have contacted my insurance company and understand what services are covered and the amount due by me, as the patient, including deductible, co-pay, and co-insurance. I have read, understood, and agree to the insurance policy.

34

Payment Options: We accept all major credit cards, checks, Venmo, Care Credit, and cash. (Returned checks will be subject to a $35 fee). If the check is returned, you will have 7 days to contact our office and arrange another form of payment. We accept cash but DO NOT HAVE CHANGE at the office. If you choose to pay by cash and do not have the exact amount, the excess will remain on your account as credit.* This field is required.

I have read, understood, and agree to these payment options.

35

Form Fee Policy: Requests to fill out forms will be charged $10/form. This includes but is not limited to: Prior Authorizations, FMLA, Driver's License, Disability, etc. Completed forms will be returned within 1 week to the patient.* This field is required.

I have read, understood, and agree to the form fee policy.

36

Credit Card on File Policy : We require that all patients provide a credit card to keep on file. We will store your card number in a secure and HIPAA compliant manner. Credit cards on file will be used for payments due after your insurance processes your claim. Balances less than $40 will be run automatically without prior notification. Balances greater than $40 will be sent a billing statement. If we do not receive payment within 13 days, we will run the credit card on file for the full amount owed. If your payment is declined, we will call you. If your reminder call is not returned within one week, a $35 declined payment fee will be applied. Your account becomes delinquent if not paid within 30 days of the original statement. The unpaid balance will be subject to a finance charge of 1.5% (18% APR) or $35, whichever is greater. Further delinquency will be subject to collections with additional finance fees.* This field is required.

I have read, understood, and agree to the credit card on file policy. I understand that the card that I use as payment for this visit will be retained on file and is the card that will be charged in the event of an unpaid balance.

37

Refunds: If a refund is available you will be notified by email/text. You will have a credit on your account. You should receive a check from Grasshopper Bank within 2 weeks to the address that we have on file. It is your responsibility to contact us if you don't receive a check. Checks are void after 90 days and we will not send additional checks. Please contact us if you have any questions: 678-590-1238

I have read, understood, and agree to the refund policy.

38

Credit Card on File Policy* This field is required.

I definitely understand the credit card on file policy. I am authorizing this office to store and run the card number that I provide here for any remaining balance after my insurance has processed my claim. I will notify this office if I wish to store an alternate card on file.

39

Covid Policy: While we clean our clinic as best we can and take preventative measures, we cannot control what or whom you come in contact with at our clinic. If you are feeling unwell for any reason, we kindly request that you reschedule your appointment. Please note, that we do still require masks for all patients and visitors regardless of vaccination status. We will update our policies in accordance with local health officials' recommendations.* This field is required.

I have read, understood, and agree to the covid policy.

40

Refill Requests: This office does NOT respond to pharmacy requests for refills. Please request all medication refills directly with Dr. Bhasin at your visit. If you need to call for a refill, please allow at least 1 week before you run out and clearly state the name of the medication, dosage, quantity requested and preferred pharmacy. If you need a refill of a medication that Dr. Bhasin did not prescribe, please contact the doctor who prescribed it for a refill.* This field is required.

I have read, understood, and agree to the refill policy.

41

Telehealth Policy: Some follow up visits may qualify for a telehealth visit. A telehealth visit is also a great option if you have additional questions or concerns after your visit. Phone calls with Dr. Bhasin greater than 5 min will be billed as telehealth visits..We are excited to offer new advanced imaging capabilities. Some ocular conditions may be amenable to telehealth exams. In those cases, you may be asked to come to the office for imaging or testing and then discuss results with Dr. Bhasin via video chat.* This field is required.

I have read, understood, and agree to the telehealth policy.

42

Privacy Policy: As a health care specialist, it may be necessary to communicate (via writing, fax, phone, email or other secure methods) to your other health care providers, health insurance companies, health insurance clearinghouses, pharmacies, labs, etc. Communication between health care professionals is in the best interest of the patient to help coordinate health care. Please note that we are a member of the Piedmont Clinic. We may be required to submit your health information in accordance with the practices of Piedmont Clinic. A copy of the Notice of Privacy Practices and Healthcare Disclosure Information that contains a description of uses and disclosures of personal health information is available on our website at www.georgiaeyeandcornea.com/privacy. The policy of this office is to be in compliance with federal and state medical practice guidelines.* This field is required.

I have read, understood, and agree with the privacy policy.

43

Assignment & Release* This field is required.

I authorize payment to be made directly to Dr. Arpita Bhasin of MedSurg Vision LLC (DBA: Georgia Eye and Cornea) by my insurance company, and I accept financial responsibility for all services not covered by my insurance. I authorize release of any health information requested by my insurance company.

44

I confirm that I am the patient (or delegated responsible party) and that the information provided in this form is correct.* This field is required.

Powered by Jotform SignClear