New Patient Forms

Patient Registration

Other Insurance (Such as Worker’s Compensation, Liability, etc.)

I certify that, to the best of my knowledge, the above information is correct and true. I do understand, however, that I am ultimately responsible for treatment- even if I am here for a Worker’s Compensation visit. I understand that I will be billed for any remaining balance after insurance has paid, and that it is my responsibility to pay this remainder. I further understand that if any insurance denies the claim, I will be billed for the entire balance.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

I authorize the release of any medical information for the HIPAA approved reasons of TPO- Treatment, Payment, and Health Care Operations. I further authorize release of payment (assign benefits) from my insurance directly to R. Stewart Shofner MD, PC (dba Shofner Vision Center). In the event that I receive a payment from my insurance company in error, I understand that I will be billed by Shofner Vision Center to obtain this payment for services that were rendered to me.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

I authorize Shofner Vision Center to notify me via land line or cell phone call, text, or email for the following:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Notice of Privacy Practice (HIPAA) Acknowledgement Form

I acknowledge that I have received a copy of the Notice of Privacy Practice (HIPAA) for the following entities: R. Stewart Shofner MD, Kevin Johnson OD, dba Shofner Vision Center.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

I authorize ONLY the following individuals to receive information about my health status, which may include protected health information via phone, email, fax, or any other method of communication:

I understand that Shofner Vision Center will only release my protected health information to the individuals listed above. All other requests for protected health information must be made in accordance to Shofner Vision Center’s office HIPAA policy and procedure manual.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Financial Policy

The goal of Shofner Vision Center is to provide you with the best care possible. Although the costs of medical care continue to rise, we will do all we can to provide affordable care, and work with you financially. Below, you will read a summary of our financial policies. Please review these carefully, initial each item, and sign and date the form.

I understand that payment is expected at the time service is rendered, unless other arrangements have previously been made. This includes applicable coinsurance and copayments for participating insurance companies.

I understand that cash, personal checks (in-state only), VISA, and MasterCard are accepted for payment. I also understand that HSA and FSA cards are accepted, provided that they have a VISA or MasterCard logo. I understand there is a $15.00 charge for returned checks.

I understand that in-house financing is not available, but I may be offered a chance to finance my care with an application through Care Credit.

I understand that I am responsible to cancel an appointment 24 hours prior to the appointment date/time. I understand that if I miss any appointment, other than Post-Op care, I may be charged $25.00.

I understand that I may be charged $25.00 for each instance of Disability/FMLA paperwork preparation.

I understand that Shofner Vision Center will file my healthcare claims to my insurance on my behalf as a courtesy. I understand that I am responsible for my deductible, copay, and coinsurance. I also understand that if the insurance denies the claim, I may be responsible to contact the insurance company, or to pay the claim in full. I may again, be offered a chance to finance my care with an application through Care Credit.

I understand that if I have a credit on my account of less than $20.00, this amount will be retained on the account to be credited toward future balances, unless a written request for the refund is received. Amounts greater than $20.00 will be automatically reviewed and refunded to the patient/guarantor.

I understand that if I am enrolled in a managed care plan (HMO), a referral, or authorization may be required before seeing R Stewart Shofner MD, or Kevin Johnson OD. I understand that this is ultimately my responsibility, and I may be asked to obtain this before treatment. I further understand that I may be responsible for payment if the referral or authorization is not obtained.

I have read and understood the Shofner Vision Center’s financial policy. I agree to assign insurance benefits to R Stewart Shofner MD, PC (dba Shofner Vision Center). I also agree that if it becomes necessary to forward my account to a collection agency for any remaining balance due, I will be responsible for any fee charged by the collection agency for the cost of the collections.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Medication and Allergy Record

Allergy Table

Reaction

Severe rashes, itching, and burning…

Medication Table

Comments

For anxiety…

Personal Medical and Ocular History

Do you currently have problems in any of the following areas?

(Please check all that apply and provide information in the comments section)

Family Medical and Ocular History

Have you, or a family member been diagnosed with any of the following? (Please check all that apply and provide information in the comments section)