Patient Forms

Demographic Information

Oxford Eye Clinic & Optical
Name *

Prefix First Name Middle Inital Last Name
Preferred Name
Date of Birth *

Month Day Year
Sex *
Social Security Number
Race *
Phone Number *
Secondary Number
E-mail
example@example.com
Address: *

Street Address

Street Address Line 2

City State

Zip Code
Marital Status *
Employment Status
Occupation/ Employer
Emergency Contact:

First Name Last Name
Contact Number
Guarantor Information

(Complete the following section if guarantor is other than self)
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.

Insurance Information

Oxford Eye Clinic & Optical
Vision Insurance *
Medical Insurance *
Vision Insurance Information:
ID Number
Member Name
Member Date of Birth
Relationship to Insured
Medical Insurance Information:
ID Number
Member Name
Member Date of Birth
Relationship to Insured
Secondary Insurance:
Secondary or Supplement Policy
Member ID #

HIPAA Compliance

Oxford Eye Clinic & Optical
I authorize my information including medical records or prescription information to be released to the following individuals:
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Relationship blank
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Name blank
Relationship blank
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Patient Name or Authorized Representative
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Patient Signature or Authorized Representative *

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HIPAA CONSENT

Oxford Eye Clinic & Optical provides this consent to comply with the Privacy Regulations issued by the Department of Health and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you as our patient. By law, we are required to make sure that your protected health information is kept private.

This is a summary of and consent for the privacy practices and patient care at Oxford Eye Clinic & Optical and serves as a condensed version of our Notice of Privacy Practices. You have the right to review our Notice before signing this Consent upon request. The terms of our Notice may change and you may obtain a revised copy by contacting our office.

If you ever believe your privacy rights have been violated, you may file a complaint with either provider of our clinic or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing complaints.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

How will we use or disclose your information? Here are a few examples: For vision, medical eye treatment or referral, to obtain payment and file insurance, in emergency situations, for appointment and patient recall reminders, to run our practice more efficiently and ensure all our patients receive quality care, prevent serious threats to health safety, for workers’ compensation programs, in response to certain requests arising out of lawsuits or other disputes.

You have certain rights regarding the information we maintain about you. These rights include: The right to inspect and copy, the right to amend, the right to an accounting of disclosures, the right to request restrictions, the right to request a paper copy of this notice, the right to request confidential communications.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent. Oxford Eye Clinic & Optical may condition treatment upon the execution of this consent.

Additionally, by signing this form, you acknowledge that by presenting yourself as a patient or child you consent for vision and medical eye care by the doctors and staff of Oxford Eye Clinic & Optical. You hereby grant full authority to the optometrists and their respective assistants to administer and perform any and all drugs, treatments, test, or diagnostic procedures to or upon me, which may be advised, or necessary.

This information and Notice of Privacy Practices is made available on request.
Oxford Eye Clinic & Optical provides this consent to comply with the Privacy Regulations issued by the Department of Health and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you as our patient. By law, we are required to make sure that your protected health information is kept private.

This is a summary of and consent for the privacy practices and patient care at Oxford Eye Clinic & Optical and serves as a condensed version of our Notice of Privacy Practices. You have the right to review our Notice before signing this Consent upon request. The terms of our Notice may change and you may obtain a revised copy by contacting our office.

If you ever believe your privacy rights have been violated, you may file a complaint with either provider of our clinic or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing complaints.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

How will we use or disclose your information? Here are a few examples: For vision, medical eye treatment or referral, to obtain payment and file insurance, in emergency situations, for appointment and patient recall reminders, to run our practice more efficiently and ensure all our patients receive quality care, prevent serious threats to health safety, for workers’ compensation programs, in response to certain requests arising out of lawsuits or other disputes.

You have certain rights regarding the information we maintain about you. These rights include: The right to inspect and copy, the right to amend, the right to an accounting of disclosures, the right to request restrictions, the right to request a paper copy of this notice, the right to request confidential communications.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent. Oxford Eye Clinic & Optical may condition treatment upon the execution of this consent.

Additionally, by signing this form, you acknowledge that by presenting yourself as a patient or child you consent for vision and medical eye care by the doctors and staff of Oxford Eye Clinic & Optical. You hereby grant full authority to the optometrists and their respective assistants to administer and perform any and all drugs, treatments, test, or diagnostic procedures to or upon me, which may be advised, or necessary.

This information and Notice of Privacy Practices is made available on request.
Patient Name or Authorized Representative
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I agree to and accept the Notice of Privacy Practices of Oxford Eye Clinic & Optical. *

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Should be Empty:

	Yes	No	Family
Cataracts
Crossed Eye
Glaucoma
LASIK or RK Surgery
Lazy Eye
Macular Degneration
Retinal Detachment

	Yes	No	Family
AIDS/HIV
Allergies
Arthritis
Asthma
Blood/Lymph Disorders
Cancer
Diabetes
Ears/Nose/Throat Conditions
Gastrointestinal Conditions
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Lupus
Neurological Conditions
Psychiatric Disorders
Seizures
Stroke
Thyroid Dysfunction

Demographic Information

Insurance Information

Secondary Insurance:

Eye History

Medical History

HIPAA Compliance