INSURANCE INFORMATION

FULL NAME
ADDRESS

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
DAYTIME PHONE NUMBER
DAYTIME HOME NUMBER
DAYTIME CELL NUMBER
E MAIL
example@example.com
NAME YOU PREFER TO BE CALLED
BIRTHDATE

MonthDayYear
Date
AGE
SOCIAL SECURITY #
EMPLOYER
EMPLOYER ADDRESS
ARE YOU A STUDENT? IF SO, YEAR?
NAME OF SCHOOL/COLLEGE
INSURANCE INFORMATION
Please list the following information about your PRIMARY AND SECONDARY MEDICAL insurance plans. Please be sure to not mix-up your PRIMARY and SECONDARY plans. Also, please do not confuse your medical and optical/vision plans. You MUST complete this information, even if you gave the receptionist insurance cards to copy.
PRIMARY MEDICAL INSURANCE INFORMATION
INSURANCE COMPANY NAME
INSURANCE NUMBER
Please complete the following information about the policy owner. If the patient is the owner, just write SELF. If the patient's spouse, parent, or guardian is the owner, complete ALL the following information on that person:
FULL NAME
BIRTHDATE

MonthDayYear
Date
SOCIAL SECURITY #
Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
EMPLOYER
EMPLOYER ADDRESS
EMPLOYER PHONE
SECONDARY MEDICAL INSURANCE INFORMATION
INSURANCE COMPANY NAME
INSURANCE NUMBER
Please complete the following information about the policy owner. If the patient is the owner, just write SELF. If the patient's spouse, parent, or guardian is the owner, complete ALL the following information on that person:
FULL NAME
BIRTHDATE

MonthDayYear
Date
SOCIAL SECURITY #
Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
EMPLOYER
EMPLOYER ADDRESS
EMPLOYER PHONE
VISION PLAN (we must know the EXACT name of your plan)
It is important that you carefully review our policies and speak to the staff before signing if you have questions!

All doctor's fees are due the same day the services are rendered. This means you must have the ability to pay these charges before you are examined. We will not bill you, or any other individual, for these services. Your insurance may pay a portion, or all of your doctor's fees, but you are directly responsible TODAY for all fees your insurance doesn't pay (such as co-pays and deductibles You may be asked to show proof that you've met your deductibles.

Our lab requires a 50% deposit on eyewear before we are able to order these items for you. The balance is due upon delivery. Contact lenses may be paid for upon delivery (custom lenses must be prepaid We are happy to accept most vision insurance benefits in lieu of payment. Be sure you check with our staff to make absolutely sure we accept your vision plan (do not assume we do You must pay the difference in your insurance coverage and the cost of your eyewear or contact lenses before delivery.

You must provide us with information regarding your insurance coverage. This includes your insurance card (opposite page In some cases we may require that you verify your coverage and specific benefits by providing us with a benefits page or booklet from your employer or insurance company (this is sometimes the only way we can verify your coverage If you are unaware of your coverage, benefits, copay or deductible status you may be asked to pay your fees today (aportion or the entire amount We may require an EOB (explanation of benefits) to verify your deductible status on certain insurance plans.

YOU are responsible for payment of your bill should there be a dispute about your claim with your insurance. If collection of your account becomes necessary, we will add the cost of collection to your account.

We also accept VISA, MasterCard. Discover and American Express.

There will be a $40 returned check charge for each returned check.

If you have read, and understood the above information, please sign below (once per date You cannot be seen without signing. If you are under 18, your parent or guardian must sign for you.
Signature*

Clear
Date

MonthDayYear
Date
Signature*

Clear
Date

MonthDayYear
Date

	Yes	No	?
Skin

	Yes	No	?
Gonads / Kidney / Bladder

	Yes	No	?
Thyroid / Other Glands

Hippa Privacy Notice:

I understand that Dr. Michael Johnson and Associates may use and disclose necessary personal health information (name, address, subscriber ID number, eve exam information, and/or other data collected from office visit) to another party to permit Dr. Michael Johnson and Associates to perform its administrative duties, to provide me with eye care services and products, process my vision care benefit claims and communicate with me regarding vision care services provided by Dr. Michael Johnson and Associates (ie. mailing of exam reminders or information about services/products provided by Dr. Michael Johnson and Associates.)

I can be assured that Dr. Michael Johnson and Associates does not sell or share my personal health information of any kind to a third party for such parties own use. I understand that Dr. Michael Johnson and Associates will submit my vision care benefits claims to my plan sponsor or health plan to receive reimbursement directly for the vision services and products that I have received from Dr. Michael Johnson and Associates.
Patient Signature*

Clear
Date

MonthDayYear
Date
Insurance Authorization:

I request that payment for authorized insurance benefits for any services furnished me, be made on my behalf to: Dr. Michael Johnson and Associates.

I authorize any holder of medical information about me to be released to my insurance company and its agents any information needed to determine these benefits or the benefits payable for related services.

I understand that I am responsible for charges not paid by the insurance plan.
Patient Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

	Yes	No	?
Headaches
Migraines
Seizures

	Yes	No	?
Loss of Vision
Blurred Vision
Distored Vision/Halos
Loss of Side Vision
Double Vision
Dryness
Mucous Discharge
Redness
Itching
Burning
Foreign Body Sensation
Excess Tearing
Glare / Light Sensitivity
Eye Pain or Soreness
Chronic Infection of Eye or Lid
Styes or Chalazion
Flashers
Floaters in Vision
Tired Eyes

	Yes	No	?
Asthma
Chronic Bronchitis
Emphysema
Sleep Apnea

	Yes	No	?
Allergies / Hay Fever
Sinus Congestion
Runny Nose
Post-Nasal Drip
Chronic Cough
Dry Throat / Mouth
Ringing in Ears
Ear Pain or Infection
Hearing Aids
Deaf

	Yes	No	?
Diabetes
Heart Disease
High Blood Pressure
High Cholesterol

INSURANCE INFORMATION

PRIMARY MEDICAL INSURANCE INFORMATION

SECONDARY MEDICAL INSURANCE INFORMATION

Patient History Questionnaire

Family History

Medical History

Social History

	Yes	No
Prominent Eyes
Eye Infection
Cataracts
Crossed Eyes
Retinal Disease
Eye Injury
Lazy Eye
Glaucoma
Drooping Eyes

	Yes	No	?
Fever
Weight Gain/Loss

	Yes	No	?
Diarrhea
Constipation

	Yes	No	?
Rheumatoid Arthritis
Muscle Pain
Joint Pain

	Yes	No	?
Anemia
Bleeding Problems