Ches Patient Form

General Patient Information
Patient Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home phone
Please enter a valid phone number.
Work phone
Please enter a valid phone number.
Mobile phone
Please enter a valid phone number.
Patient Gender*
Patient Birth Date*

MonthDayYear
Social Security Number
Patient E-Mail*
example@example.com
Required by government mandate (although you may refuse).
Language:
Race:
Ethnicity:
Marital status:
(Single, Married, Divorced, widow)
Other
Patient referred by:
Primary care provider:
Contact preference:

Home phoneWork phoneMobile phonePortalE-mail
Primary insurance information
Please check the box if you don't have a valid insurance.

I don't have an insurance
Insurance plan name:
Policy holder:

First NameLast Name
Address (Policy holder):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Gender*
Employer name:
Patient's relationship to policy holder:
Secondary insurance information
Insurance plan name:
Policy holder:

First NameLast Name
Address (Policy holder):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date

MonthDayYear
Gender
Employer name:
Patient's relationship to policy holder:
Guarantor information

To whom statements are sent
Same as patient
Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to patient:
Birth Date

MonthDayYear
Social Security Number:
Phone number:
Please enter a valid phone number.
Emergency contact information
Name:*

First NameLast Name
Relationship to patient:
Phone number:
Please enter a valid phone number.
Mobile phone number:
Please enter a valid phone number.
Employer information
Do you have an employer right now?*

Yes (Please fill the following fields)No
Name:
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number:
Please enter a valid phone number.
Pharmacy information
Name:
Address:
Phone number:
Please enter a valid phone number.
Medical History
Amblyopia (Lazy eye).*

YesNo
Note
Anxiety Disorder*

YesNo
Note
Arthritis*

YesNo
Note
Blood disorders*

YesNo
Note
Cancer*

YesNo
Note
Coronary Artery Disease*

YesNo
Note
Depression*

YesNo
Note
Diabetes*

YesNo
Note
Diabetic Eye Disease*

YesNo
Note
Double Vision*

YesNo
Note
Eye Trauma (direct to eye)*

YesNo
Note
Eye Disease*

YesNo
Note
Flomax Use Past or Present*

YesNo
Note
Gastrointestinal Disease*

YesNo
Note
Genitourinary Disease(Reproductive/Urinary*

YesNo
Note
Headaches*

YesNo
Note
Heart Disease*

YesNo
Note
High Cholesterol*

YesNo
Note
Hypertension*

YesNo
Note
Hospice Care*

YesNo
Note
Lasik / PRK*

YesNo
Note
Liver Disease*

YesNo
Note
Lung Disease*

YesNo
Note
Meningitis*

YesNo
Note
Multiple Sclerosis*

YesNo
Note
Neurologic Disorder*

YesNo
Note
Ocular Trauma*

YesNo
Note
Psychiatric/Mental Condition*

YesNo
Note
Seasonal Allergies*

YesNo
Note
Sleep Apnea*

YesNo
Note
Stroke*

YesNo
Note
Thyroid Disease*

YesNo
Note
Eyelid and/or Facial Cosmetic Procedures*

YesNo
Note
Would you be interested in getting information about:
Eyelid and/or Facial Cosmetic Procedures*

YesNoMaybe, tell me more
Botox®*

YesNoMaybe, tell me more
Laser Skin Resurfacing*

YesNoMaybe, tell me more
Facial Fillers (Juvederm®)*

YesNoMaybe, tell me more
Lip Enhancement*

YesNoMaybe, tell me more
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CASTLE HILLS EYE SPECIALISTS FINANCIAL POLICIES

The best medical care can only be provided only on the basis of mutual understanding. We encourage you to discuss any questions you may have regarding our policies with our billing staff.
Insurance

We participate in a variety of insurance plans (list can be provided) and will directly bill your insurance under these plans. In this circumstance, you are responsible only for applicable co-payments before the visit. If you have not met your deductible, you may pay at the time of your visit or we will bill you after we receive a response from your insurance company. We cannot accept responsibility for negotiating claims with insurance companies. You are responsible for payment of your medical care within a reasonable time, regardless of the status of a claim. Services not covered by your insurance are you responsibility.

Co-Payments

When your insurance specifies a co-payment (usually indicated on the ID card), this payment must be made at check-in, prior to your exam.

Prior Authorization and Vision Care Forms

Some health maintenance organization (HMO) plans require you to obtain authorization for services from your primary care provider (PCP). It is your responsibility to obtain authorization from your PCP. This is required by your insurance before you visit our office, even when the visit is for an urgent problem. Contact your insurer or the office of your PCP.

We Participate with Medicare

We are participating providers under Medicare. This means that we accept the fees set by Medicare for medical services covered by the Medicare program, including surgery. Medicare patients will be responsible only for co-payments, deductibles and non-covered services, such as refractions and routine eye exams.

Credit Cards

For your convenience, we accept Visa, Mastercard, American Express, Discover, Care Credit and Alphaeon.

Billing

If billing is necessary, a statement will be mailed to you, which is due within 30 days. Charges and payments for services received during the last few days before your billing date may appear on the following month's statement.

Insurance Counseling

Before any surgical procedure or exam which may entail greater expense, our office will provide insurance coverage information and estimate what, if any, balance may remain once insurance has paid. At your request, we will provide information on coverage to the best of our ability for any examination or procedure we perform, even when not of great expense. If special financial circumstances warrant an extended payment plan, our staff will be glad to help you.

Refractions for Eyeglasses

If you are requesting a prescription for eyeglasses., you will need to have a refraction done by your provider. Unfortunately, this service is not covered by Medicare nor private insurance plans. The fee for this service is $45.00 and will need to be paid prior to services being rendered. If you have any questions, please feel free to ask our staff.

Hospice Patients

Please provide hospice information to the front desk. You may also have your representative provide this information.

Revised 01/17/2022
NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please advise the front desk if you would like a copy for your records.
Understanding Your Health Record/Information

Each time you visit a hospital, physician or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnosis, treatment and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

● Basis for planning your care and treatment

● Means of communication among the many health professionals who contribute to your care

● Legal document describing the care you received

● Means by which you or a third-party payer can verify that services billed were actually provided

● Tool in educating health professionals

● Source of data for medical research

● Source of information for public health officials charged with improving the health of the nation

● Source of data for facility planning and marketing

● Tool with which we can assess and continually work to improve the care we render and the outcomes we achieve

Understanding what is in your record and how your health information is used helps you to:
● ensure its accuracy

● Better understand who, what, when, where and why others may access your health information

● Make more informed decisions when authorizing disclosure to others

Your Health Information Rights

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:

● Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522. Requests for restrictions on disclosures to your health plan for health care items or services paid out of pocket must be accepted.

● Obtain a paper copy of the notice of information practices upon request

● Inspect and obtain a copy of your health record as provided for in 45 CFR 164.524 and HB 300 (paper or electronic).

● Amend your health record as provided in 45 CFR 164.528

● Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528

● Request communications of your health information by alternative means or at alternative locations

● Revoke your authorization to use or disclose health information except to the extent that action has already been taken

● Receive a notice of a breach of “unsecured” protected health information

Our Responsibilities
This organization is required to:

● Maintain the privacy of your health information

● Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
● Abide by the terms of this notice
● Notify you if we are unable to agree to a requested restriction
● Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations
● Notify you of a breach of “unsecured” protected health information

We reserve the right to change our practices and to make the new provisions effective for all protected health information (PHI) we maintain. Should our information practices change, we will mail a revised notice to the address you have supplied us.

We will not use or disclose or sell your health information without your written authorization, except as described in this notice.

To Report a Problem

If you have questions and would like additional information, you may contact the Privacy Officer at this office.

If you believe your privacy rights have been violated, you can file a complaint with this office or with the secretary of Health and Human Services. There will be no retaliation for filing a complaint.

Examples of Disclosures for Treatment, Payment and Health Operations
Treatment: Information obtained by a nurse, physician or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment. We will also provide subsequent healthcare providers with copies of various reports that should assist them in treating you.

Payment: A bill may be sent to you or a third-party payer. This information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used.

Health Operations:

1. Risk Management - Members of the medical staff or the risk or quality improvement staff may use information in your health record to assess the care and outcomes in our case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

2. Business Associates - There are some services provided in our organization through contacts with business associates. Examples include radiology, laboratory, copy services, transcription services, billing services, etc. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

3. Notification - We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location and general condition.

4. Communication With Family - Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify health information relevant to that person’s involvement in your care or payment related to your care.

5. Research - We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

6. Funeral Directors - We may disclose health information to funeral directors consistent with applicable law to carry out their duties.

7. Organ Procurement Organizations - Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs for the purpose of tissue donation and transplant.

8. Marketing - We may contact you to provide appointment reminders or face-to-face information about treatment alternatives or other health-related benefits and services that may be of interest to you.

9. Food and Drug Administration (FDA) - We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, recalls, repairs or replacement.

10. Workers’ Compensation - We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs established by law.

11. Public Health - As required by law, we may disclose your health information to public health or legal authorities charges with preventing or controlling disease, injury or disability.

12. Law Enforcement - We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

13. Schools - We may disclose childhood immunization records to schools.

Federal law makes provision for your health information to be release to an appropriate health oversight agency, public health authority or attorney, provided that a workforce member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

This notice is effective as of Oct. 21, 2014 and will remain in effect until revised.
NO SHOW, LATE CANCELLATION & LATE ARRIVAL FEE POLICY

Our goal at CASTLE HILLS EYE SPECIALISTS is to provide quality medical care in a timely manner. In order to do so, we have had to implement an office policy that addresses no-shows (a missed appointment without a 24-hour notice before the scheduled appointment), late appointment cancellation (calling the same day as the scheduled appointment) and late appointment arrivals (20 minutes late for a scheduled appointment).

How To Cancel Your Appointment

To cancel appointments, please call 210-348-8788. If you do not reach the receptionist, you may leave a detailed message on the voice mail 24-hours before your scheduled appointment. You also have the option to respond to the reminder telephone calls and/or text messages that you will receive 2-3 days prior to your scheduled appointment.

No-Show For Scheduled Appointments

There will be a $25.00 fee added to the patient account which is not covered by patient insurance for missing a scheduled appointment without giving a 24-hour notice of cancellation.

Late Cancellation of Scheduled Appointments

Same day appointment cancellations will be considered a no-show and will have a $25.00 fee added to the patient account which is not covered by patient insurance.

Late Arrivals for Scheduled Appointments

If you arrive 20 minutes or later for a scheduled appointment without any notification to our office, the patient will be automatically re-scheduled for another day and be assessed the $25.00 late arrival fee.

I HAVE READ AND UNDERSTAND THE ABOVE CASTLE HILLS EYE SPECIALISTS PRACTICE POLICIES. By respecting these policies, together, we will be able to meet the medical eye care needs of all our patients in a way that will allow each patient the right amount of time to be seen by Dr. Sepulveda and his staff. THANK YOU.
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To the best of my knowledge the above information is complete and accurate.

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ACKNOWLEDGEMENT AND AUTHORIZATION:

*Please sign and date each item below*
I have read and understand the HIPAA/Privacy Policy for CASTLE HILL EYE SPECIALISTS PA
YesNo
I hereby assign my insurance benefits to be paid directly to the healthcare provider
YesNo
I authorize CASTLE HILL EYE SPECIALISTS PA to release medical information required to process my claim
YesNo
I have read and understand the Financial Policy for CASTLE HILL EYE SPECIALISTS PA
YesNo
I authorize CASTLE HILL EYE SPECIALISTS PA to obtain/have access to my medication history
YesNo
I authorize my provider’s office to contact me by mobile phone
YesNo
Signature

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Date

MonthDayYear
Date in which you signed filled up this form.
Should be Empty:

General Patient Information

Required by government mandate (although you may refuse).

Other

Primary insurance information

Secondary insurance information

Guarantor information

Emergency contact information

Employer information

Pharmacy information

Medical History

Would you be interested in getting information about:

How did you hear about us?

CASTLE HILLS EYE SPECIALISTS FINANCIAL POLICIES

NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES

Heading

To the best of my knowledge the above information is complete and accurate.

ACKNOWLEDGEMENT AND AUTHORIZATION:

I have read and understand the HIPAA/Privacy Policy for CASTLE HILL EYE SPECIALISTS PA

I hereby assign my insurance benefits to be paid directly to the healthcare provider

I authorize CASTLE HILL EYE SPECIALISTS PA to release medical information required to process my claim

I have read and understand the Financial Policy for CASTLE HILL EYE SPECIALISTS PA

I authorize CASTLE HILL EYE SPECIALISTS PA to obtain/have access to my medication history

I authorize my provider’s office to contact me by mobile phone